Prevention of Health Care Fraud and Abuse

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Prevention of Health Care Fraud and Abuse

Introduction

The health care fraud and abuse are activities which involve a fraudulent acquisition of healthcare programs funds or property. The abuse is an unintentional practice resulting in the overpayment by a healthcare program. Such activities are widespread and common. They include billing for services not provided, providing unnecessary service in order to inflate the payments, and other similar schemes. The health care fraud results in a tremendous loss of funds by the governmental healthcare programs and sometimes affects the patients negatively. The total damage to the US healthcare system due to fraud abuse and waste is estimated to be $700 billion dollars (Thornton, Mueller, Schoutsen, & van Hillegersberg, 2013). All of that money could have been spent on treatment and support of the patients. Not to mention, certain fraud practices expose patients to the additional health risks, like the unnecessary surgeries. Preventing and reporting fraud and abuse is the only way to limit the negative effects they have on the healthcare system.

Ethical, Socioeconomic, and Physiological Issues of Health Care Fraud

Some people consider the health care fraud a victimless crime since it does not seem to directly affect the patients. However, that view is near-sighted. The analysis of the cases presented in the study shows how fraud can be extremely harmful to the health care system and to specific patients. In the AmeriGroup example, the fraudulent actions caused a disruption in the work of the Medicaid system and prevented people from getting the services they needed (Rudman, Eberhardt, Pierce, & Hart-Hester, 2009). Other cases of the document fraud demonstrate loss the health care system suffers. That money could have been used to treat the people in need, but ended up in the pockets of the conmen. The case of the dermatologist from Florida represents the direct harm the fraud can cause to the patients. The dermatologic surgery results in complications only for 1.7-8.6% of the patients depending on the type of the procedure (Bordeaux, et al. 2011).

However, the 3,086 unnecessary surgeries performed in that example mean that, statistically, 51 to 258 patients suffered from some complications. Dermatologic procedures rarely have a lasting negative effect, but exposing patients to additional risks is unethical and contradicts the basic principles of healthcare. Any fraudulent action presents additional risks for the patients either through potential harm of unnecessary surgeries and medication or through limiting the access to the essential services needed to support their lives and wellbeing. It is not a victimless crime and only seems to be one since not everybody understands the situation in which a perpetrator puts the patients. Not to mention, the other victim is the health care system as a whole. It is designed to help those who cannot help themselves. Abusing it to make money contradicts every principle of the medical ethics imaginable.

Responsibilities of Medical Workers Facing Health Care Fraud

If I am unfortunate enough to find myself involved in the healthcare fraud scenario, several steps will be needed. First, I would need to check and figure out whether the fraud is actually taking place. Sometimes negligence and poor organization lead to the unintended abuse. If that is the case, reporting the problems to the management will be my first priority. After that, I will need to observe how the situation changes and take the case to the higher instance in case there are no improvements. If, however, there appears to be an actual fraud scheme, reporting the case to the authorities is the only way to go. Since the local police might be a part of the scheme, it is probably a better idea to use the online services of the FBI or the Department of Justice to submit your report. From there on in, the medical ethics dictate you to support the investigation and help bring the fraud to light (Ogunbanjo & van Bogaert, 2014).

Sentences and Fines Related to Health Care Fraud

The problem of healthcare fraud is more severe than most people realize. It has an adverse effect on the efficiency and availability of the healthcare programs. It can put patients at risk of unnecessary complications and health damage. Those facts justify the sentences and fines related to the presented cases. The fraud is difficult to identify and control, so even if it is uncovered the damage already done usually is enormous. The fines serve as compensation for the health care system, and imprisonment is needed to discourage such behavior among the medical professionals. While strong ethical education can help prevent some of the issues, the temptation to get free money from a seemingly victimless crime can be strong. The sentencing related to the fraud cases is the only way to lessen it.

Conclusion

Avoiding healthcare fraud and abuse is one of the key ethical responsibilities of all health care workers. As the cases listed above illustrate, such actions result in tremendous loss of efficiency and potentially endanger the patients. Allowing them to continue through negligence or cooperation means violating your primary responsibility as a medical professional providing healthcare to as many people as possible, as efficiently as possible.

References

Bordeaux, J., Martires, K., Goldberg, D., Pattee, S., Fu, P., & Maloney, M. (2011). Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. Journal Of The American Academy Of Dermatology, 65(3), 576-583.

Ogunbanjo, G.A. & van Bogaert K.D. (2014). Ethics in health care: healthcare fraud. South African Family Practice, 56(1), S10-S13.

Rudman, W.J., Eberhardt, J.S., Pierce, W., & Hart-Hester, S. (2009). Healthcare Fraud and Abuse. Perspectives in Health Information Management, 6, 1-24.

Thornton, D., Mueller, R., Schoutsen, P., & van Hillegersberg, J. (2013). Predicting Healthcare Fraud in Medicaid: A Multidimensional Data Model and Analysis Techniques for Fraud Detection. Procedia Technology, 9, 1252-1264.

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