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Motivators of Fraud in Health Care Essay

What are the motivators of Health Care fraud? At first thought, I suspect it was for the love of money but then I felt like it has to be more to it than that. Why would people risk it all to defraud insurance companies and even the government? After a while, it’s clearly not about the money because the longer a company goes without being caught, they won’t be hurting for financial wealth so why continue? How do you know when you are being charged for test and check that you don’t need? During this essay, I will answer these questions as well as describe what acts as motivators for these health Care frauds. According to the text, the health care industry is the (single largest single industry) in the United States economy.

The structure of today’s health system, it leaves huge opportunities for fraud to take place. Back in the early 1980’s; doctors would provide medical care to patients and then later file a claim with the issuance company of the patient or send a bill in the mail for the patient. Prior to a doctor submitting his or her bill, it would be reviewed by a medical coder who was able to determine the legitimacy of treatment that was required. With the presence of modern technology, doctors file their claims but now they are reviewed by computers which open the door for more opportunities to defraud the insurance companies. In these situation, I feel the fraud in this case is motivated by the fact that those insurance companies don’t find it very important to review claims and therefore are only getting always with what insurers are allow to.

Those committing healthcare fraud include organized criminal groups, individuals, and health care providers. The individuals committing healthcare fraud see the crime as low risk and high reward since many perpetrators are never caught. If they are caught the penalties are relatively less severe than other crimes. For example, in a 2010 study on the effectiveness of healthcare fraud taskforces, the average convicted offender received three to five years, but the total amount of fraudulent billings in the 200 sampled cases exceeded a billion dollars. The most common form of fraud is false billing. There are a wide variety of billing schemes, but generally a person committing fraud will bill an insurer for a service that was never performed. For example, many perpetrators will obtain patient information from hospitals or other sources and use that information to charge both public and private health programs for false reimbursement claims.

How can you tell when you are at risk of being charged for treatment not received or not needed? Picture this scenario, a lady goes into a minimum care facility and tells the receptionist that she has a pain in her hand, the receptionist tells her that she needs an X-rays. The patient responds by wanting to see the doctor first. The receptionist tells that patient that it is protocol that they get X-rays before the doctor will see her. The lady gets the X-ray and is then seen by the doctor who finds a cyst and the patient is treated and released. In that scenario, this medical facility disguised unneeded charges by “protocol.” No one actually knows the extent or motivators of fraud in healthcare, we have only estimates and the bases for them often seem a tad bit flimsy. I feel that Healthcare frauds happen for two reasons, greed for financial superiority and there is no jail time in most cases.

First of all, Healthcare is rarely paid for out of pocket and the consumers of the healthcare services have little incentive to check their bills. Unless the actual payer of the bills follow-up with the receiver of the service or treatment, the crimes of overcharging, will go unnoticed. The insurance companies, private and public third-party payment programs, were not in the room when the services were provided and do not know whether they were needed or actually supplied. Finally, when a doctor makes 10 million dollars because of overcharging, charging for services not required or not given and he is only fined 5 or 6 million dollar and there’s no jail time. He still came out on top and continues to practice medicine because he rationalizes it by blaming it on the patients, bookkeepers and even the government.

References
Benson, M. L. & Simpson, S. S. (2010). White-Collar Crime: An Opportunity Perspective, research, 9-12. https://www.nampi.org/members/2010presentations/KeynoteAddress.pdf http://mjpetro.typepad.com/7th_circuit_alert/2011/07/42-usc-1320a-7b-medicare-fraud-primary-motivation-doctrine-rejected.html


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