There are many crimes committed daily. Many people wouldn’t consider this specific crime to be as serious as murder or rape. Overall, it is still very important. Crimes in the Health Care System is a very serious White-Collar Crime. There are many elements with crimes in the health care system. Fraud by Doctors, Unnecessary Surgery, Medication Errors, Fraud by Pharmacists etc. The most important topic is Fraud by Doctors.
Fraud by Doctors is a very serious matter. There is a certain level of trust that you give someone who knows everything about you. It is very concerning to know that they may be sharing your personal information with others or committing fraud. According to the textbook, “The most pervasive form of Fraud committed by doctors entails the commission of Medicare and Medicaid fraud and abuse. (Payne, 2013) By using the Medicare and Medicaid as a form of fraud the Doctors are taking money from innocent people. They are making up claims and charging for visits that never happened in the end the only person that suffers is the insurance companies and the patients.
“It is estimated that between 3 and 10 percent of health care spending is lost to fraud.” (Payne, 2013) Some people are not aware that their insurance companies are being charged for visits or other things even though they may have never been seen by a doctor. In my opinion,
a great target for Doctors would be elderly patients that may not be aware of their payments and doctor bills. Elderly patients aren’t going to question their insurance company if a doctor visit mysteriously raises in price or if they get a bill in the mail for compensation for a visit that they never received.
“The Medicare and Medicaid Anti-Kickback Statue (“AKS”) is the main federal fraud law applicable to financial relationships within the healthcare market, including relationships between providers and their patients and between healthcare manufacturers and their customers.” (Krause, 2012) Kickbacks are used as way to get monetary gain from other doctors and their patients. For instance, if you schedule an appointment to see your primary care doctor for an illness. And as a result of the illness you need surgery. Your primary care doctor will refer you to a surgeon. But have you ever noticed that they won’t name multiple surgeons? They usually name one surgeon that they are aware that does the specific procedure that you need. In other words, they are more than likely in a kickback situation with the doctor that they referred you to.
Training and Education play a major role in Healthcare Fraud. For instance, when you are studying to be a doctor you may not know all of the problems that may occur along the way. Many doctors follow what they are taught in training and what they learned in their programs in college and etc. If you are trained to be a corrupt doctor or to steal from patients then that is what you will practice. “Implementation of fraud and abuse education and training programs may be facilitated through establishing corporate or staff coding committees to create standards and protocols. (e.g., standard abbreviations, documentation for medical necessity).” (Rudman,2009)
Doctors need to be better trained and aware of how not to commit healthcare fraud. They should be evaluated every five to ten years on their work and the practices they use.
Another form of healthcare fraud is upcoding. Upcoding is defined as: “refers to situations where providers bill for services that are more expensive then the services that were actually provided.” (Payne,2013) Upcoding is a major problem because offices are receiving large payments for services that weren’t worth half of what they received payment for. This is a type of fraud because the doctors are charging the patients insurance companies for more money than the treatment that the patient received. Most Patients never go in depth about what their insurance companies are being charged because they figure that the insurance companies will handle the expenses and they will pay the remaining amount out of pocket.
Another example of Healthcare fraud is Fraud by Pharmacist. Many people. May think that there is no way that a Pharmacist can commit fraud. It is easier than you think. A pharmacist can get a prescription note written by a doctor for a patient and they can say that they misinterpreted the three for a five or something in that nature. Ultimately, what they do is request more medicine than what is required and they either take it home or stash it in a place that only they will know that it is there. According to the article, Compounding Fraud Scheme: Pharmacies in Tampa and Miami were working with eight men from within the area to commit Pharmacy Fraud. “The pharmacies submitted approximately $633 million in claims for prescription compounded medications and received approximately $157 million in reimbursement based on the claims.” (Mena Report, 2016)
There are many changes that can be made to correct and overall deter healthcare fraud. Healthcare fraud didn’t begin with one person and it will not end by being stopped by one person. Overall, I think doctors and Pharmacist and everyone in the medical field need better training and education on fraud being committed in the healthcare system. Some people may not know they are committing fraud until they are too far gone and don’t know how to control it and they don’t know how to stop or don’t want to stop. A pharmacist or doctor is not going to know how to commit fraud or do fraudulent things unless they are shown or taught how to.
According to the article Health Care Fraud and Abuse, “One of the most effective ways of controlling fraud and abuse is through reinforcement of federal penalties.” (Rudman, 2009)
I think that statement is very true because if a person knows that if they are caught doing fraudulent things and know that there are federal consequences for the fraudulent behavior they will be less likely to commit Healthcare Fraud. Aside from training and education I think that is the most effective way to stop Fraud in the Healthcare system. Also stated in the article, “During 1988 and 2000, the federal government recovered slightly over $1.8 billion from healthcare providers who committed fraud.” (Rudman,2009) Healthcare fraud has been going on for years and people are caught committing fraud all of the time. I think once you get the government and federal people involved then people become scared and stop committing fraud.
When people know that there are consequences and strict laws against a crime they are less likely to commit the crime. But if they see others getting away with it and not being caught then they think that they will be okay to do it also. If there are televised and new stories about people being punished for committing healthcare fraud I think then people will see the real harm in the situation. Overall, I think with better Training and understanding of Fraud and the harm that it does to not only the insurance companies and the patients also the doctor offices and employees involved. People will be better educated and encourage others not to commit fraud. I also think that there should be televised and printed awareness seminars and rallies against Fraud in the Healthcare System. The more people are aware the less it will transpire and the consequences need to be fair and strict.
