Healthcare Compliance to Detect and Thwart Healthcare Fraud
Healthcare fraud related crimes are on the rise in the United States. The recent arrest of 111 doctors, nurses, and healthcare professionals in a massive healthcare fraud estimated at $225 million, involving criminal false claims, identity thefts, money laundering, and conspiracy to trick Medicare, is enough to prove the current state of affairs in the healthcare industry. Healthcare fraud is a thriving industry thanks to the unscrupulous attitude of certain patients, doctors, and even pharmacies.
Medicare
Medicare is a social insurance program implemented by the United States government to provide health insurance coverage to those who are disabled and to those who are 65 and older. Medicare has been a target for fraud because medicare claims are processed quickly. Moreover, since the healthcare providers themselves file medicare claims on behalf of the patients it makes matters easy for fraudsters and scamsters.
Types of Fraud
As noted above, health care fraud has become a booming business in the United States and the fraudsters stop at nothing to make easy money. The following are some of the typical frauds found in the healthcare industry.
- Billing for procedures, medical tests, or services that are either needless or never performed
- Billing for expensive services that are unnecessary
- Inflating bills for those services that are either free or inexpensive
- Making separate bills for services that can be bundled together
- Accepting kickbacks and bribery for patient referrals
- Using the identity of others to make false insurance claims
Importance of Legislation
In most healthcare frauds, the healthcare providers are found to be the perpetrators. Be it Doctors, Dentists, Chiropractors, Psychologists, Nursing Care or any practice, since they handle Patient Health Information (PHI), it is very easy for them to find easy targets. Realizing the helplessness of the patients, the United States government decided to act tough and enacted various legislations to protect patient health records and safeguard them from becoming a pawn in the hands of healthcare fraudsters.
The ARRA Act
The United States government introduced the American Recovery and Reinvestment Act commonly referred to as the Stimulus or the Recovery Act to help the country recover from recession. As part of this act, the government allocated around $155 billion towards the improvement of the healthcare industry. The ARRA act also brought into effect two federal laws known as the HIPAA compliance and HITECH Acts to crack down on healthcare fraud. With the government making the ARRA act binding on all, medical practitioners, healthcare providers, and business associates have no other choice but to ensure healthcare compliance so that they are not on the wrong side of the law.
In healthcare industry, corruption is widespread and deeply embedded and therefore enforcing these kinds of acts is the only way to clean up the mold that has penetrated deep in the healthcare industry.
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