Jane Karen

 101 Ways Doctors Steal From Taxpayers.   Healthcare fraud is a form of white collar crime that is committed by healthcare providers, consumers, companies that provide medical supplies or services, and health care organizations. It is currently one of America's largest taxpayer rip-offs ever. It is costing American billions of dollars every other year. For example in Florida, Medicare fraud booms far much more than the drug trade. Rather than making $200,000 - $300,000 from drug sales, physicians can steal millions of Medicare reserve. City of Angels Medical Center in Los Angeles once recruited homeless people from the streets, offered them food and money while they billed Medicare millions of dollars for their stay. In other scenarios, black market companies provide lists of Medicare patients that come complete with their names in full, social security numbers, dates of birth and addresses. Criminals can easily bill the government for a patient once they are armed with those four pieces of information. Copies of such information sell for $10 per patient in the black market. Fraudsters purchase thousands of these lists and bill Medicare. These details are stolen from doctor’s offices and other medical institutions. A good number of such charges go unnoticed simply because Medicare auditors only manage to check a small fraction of these charges to see if the claims are legitimate. As you can see, healthcare fraud is characterized by deliberate deceit, disguise and violation of trust. It is committed by people and organizations whose aim is to obtain personal or business advantage. It is simply a trend towards increased participation by well organized cartels in complex healthcare fraud schemes (NHCAA:2008) Healthcare fraud is comprised of many different types of illegal and unethical schemes. To fully appreciate what healthcare fraud looks like, it is important to first understand the players. a. The patient is the person who receives healthcare services and products b. The Healthcare provider is the entity or individual that delivers or executes healthcare services or products, probably a hospital, clinic, homecare, Psychiatric care etc. c. Insurance provider can either be, a self- insurance program, an employer based premium program or a government program such as Medicaid and Medicare. What does Healthcare Fraud Look Like From Healthcare Providers Perspective? The fraud scheme may vary from complex financial arrangements to false claims. It may include:- Billing unnecessary treatments, medical services or tests that were not provided. Billing the insurance company for services that were never rendered also known as Phantom Billing. Exaggerating or faking the severity of the medical illness to justify coding Billing for a more expensive procedure or diagnosis also known as up coding Accepting kickbacks for a referral for medical services or goods. Billing for old items as if they were new Charging Medicaid/Medicare for expenses that are not associated with caring for a Medicaid patient Lying about ownership in a related company Using other persons insurance card Double billing for health care services or goods that were provided Stealing medical info and billing health insurance providers for phantom treatments Psychiatric care, homecare, long-term care and large corporate healthcare organization are the main areas of Healthcare that have suffered the most fraud. Does Healthcare Fraud Affect the General Cost of Health? Due to rampant deception, scams and abuse in the health care system, Americans are forced to bear the price through escalating medical costs and ever increasing health insurance premiums. As a result, government programs like Medicaid and Medicare that were originally designed to help the low-income and elderly people are becoming the biggest losers of all. You see, the Medicare system was established in the 1960’s based on trust. It was assumed that no one would ever defraud a system that was designed to cater for the elderly. To curb this, Health Insurance Portability and Accountability Act of 1996 (HIPAA) established healthcare fraud as a federal criminal offense. The crime carries a federal prison term of up-to 10 years in addition to significant financial penalties. The prison term can double up to 20 years if fraud results in injury. The perpetrator can also be sentenced to life in federal prison if the fraud results in death of the patient. You will be surprised to know that healthcare fraud increases the cost of healthcare for every American citizen. Essentially, how much money gets stolen? National Health Care Anti-Fraud Association (NHCAA) estimates the magnitude of this problem could amount to billions of USD dollars. If, America is lucky enough, then, probably just a hundred billion dollars. Well, most likely three or four hundred billion dollars if not five. When this loss occurs, insurance companies must make up the losses in one way or another. Some of the main ways that private Insurance companies cover for this is to increase premiums, copayments and deductibles. For Medicaid and Medicare which are government owned programs, the increased costs become a burden that is carried by all taxpayers in the USA. How Health Insurance Fraud is Committed Health insurance fraud revolves around money and reimbursement. It is not dependent upon the application of violence or threat or physical force. In the early 90s, the federal government investigated and revealed major fraud and abuse in the health system and this became the whistle blower. This fraud represented a loss of $100 billion (US House of representatives, 1994) The Culprits of that fraud investigation were mainly doctors, pharmacists, medical equipment companies and healthcare organizations. That investigation revealed a shocking insidious type of insurance fraud that targeted Medicare and Medicaid schemes. Up till now the perpetrators continue to rob all taxpayers off their hard earned contributions to Medicare and Medicaid. Can Individuals Protect Themselves from Healthcare Frauds? First and foremost, it is important to know that if health insurance scams come knocking on your door, they could leave you with a damaged credit rating, huge medical debts, falsified health records, hiked health insurance premiums and not forgetting high level of stress. The worst case scenario is the likelihood of leaving you unable to ever get any health insurance ever again. So keep your eyes and ears open for abuse. On top of that, be extra vigilant for healthcare providers who: Charge your health insurance provider for medical procedures you did not need or charge for services you never received. Give you prescriptions for controlled substances even when there is no justified reason medically. Bill your insurance provider for Original drugs or branded drugs when you actually got generics Misrepresent health care procedures or cosmetic procedures that are not usually covered by health insurance plans as covered for example clipping your toenails at a health fair and billing for foot surgery or offer a free Medicare Approved Arthritis Kit that may consist of a back brace, knee brace, elbow brace, ankle brace, and heating pad for which they bill Medicare for over $ 1000 and have invested less than $100 Pressurize you into obtaining a medical device or transportation device such as wheel chair or scooter that you may not be in need of. Offer home health care for which you do not qualify Provide ambulance service to take you to the doctor, physical therapist, or dialysis for free but then charge the program for a non-emergency trip Fighting Health Insurance Fraud The only way that you can protect yourself from falling victim to health insurance fraud is by taking the following steps: Protect your health insurance ID card like you would a credit card. Be careful about disclosing your insurance information. If you lose your insurance ID card, report it to your insurance company immediately. Watch out for those health providers who may ask you for your social security number. Protect yourself from identity theft by trying to get them to accept another form of identification because all information goes into a computer database that could be hacked or accessed by a disgruntled member of staff. Call your insurance company and report fraud the moment you suspect that you have become a victim of healthcare fraud. You can now report suspected fraud online since many insurers are offering that opportunity though their websites. Read your policy and benefits statements. Make sure you understand how your policy talks about explanation of benefits (EOB) statements and any paperwork you receive from your insurance provider. Make sure you were tested or received treatment for which your insurance was charged if not then, question suspicious expenses. The dates of service documented on the forms must be correct. Ensure that the services identified and billed for were actually performed. Never encourage your healthcare provider to make erroneous entries on certificate bills or records in order to have your insurer pay for an item or service. Free from providers who tell you that an item or service is not covered but they know how to bill your private insurer or Medicaid pay for it. Do not attempt to maintain a family member, such as a divorced spouse or a grown up child, on your policy if the person is no longer eligible. In conclusion, healthcare fraud is costing American taxpayers roughly $60 million every year, that’s according to a post on Washington Post. It is, therefore, the duty of every citizen to safeguard their own information and prevent any form of fraud from taking place in their own medical circles. Fraud would probably go away if every person is willing to carry out this kind of prevention. It is quite unfortunate that there are people out there whose sole purpose is to swindle the American government for their own gain. Play your part; protect your information because Healthcare fraud hurts every single one of us.