A Study On The Causes Of Healthcare Fraud

Running head: HEALTHCARE FRAUD 1

A study on the causes, implications and remedy to health care frauds in the healthcare sector.

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HEALTHCARE FRAUD 2

Abstract

Healthcare continues to diversify regarding service delivery, professional responsibility as well

as its profits to the society. Medical practitioners have continued to raise false and baseless

claims and as a result, not much remedy for them comes into play. Data mishandling and

manipulation have become methods towards facilitating fraud and abuse in the healthcare sector

which has harmed both service delivery and eradication of diseases such as malaria. For instance,

a demographist in Florida got sentenced to a 22-year prison term due to patient fraud. The paper

will seek to identify the types of fraud, the basis of fraud as well as the measures taken to address

the problems it has provided. Also, it will offer a critical analysis of the results on the already

employed measures.

Key terms: Healthcare Fraud and abuse, ambulatory health care, accreditation, care

management, cognitive service, eligibility and occupation

HEALTHCARE FRAUD 3

A study on the causes, implications and remedy to health care frauds in the healthcare

sector.

In the United States’ health sector, public funding to an estimate of about 3-15 percent of

public expenditure funds gets lost through fraud and abuse. The 1998 federal government’ False

Claims Act aimed at fraud and ill-treatment provided for treble damages in the court where the

government prosecutes the violators.

Violations of the provisions of public health policies and ethical standards in the

healthcare sector have escalated and as a result hindered the delivery of the services that the

industry intends to offer to its clients. Many violations have gone unnoticed with others getting

noticed and the violator evading punishment through weak legal systems especially in the less

developed countries and as well the developing ones although the rates of the cases differ.

Healthcare fraud becomes the practice of knowingly and willingly committing a scheme

or an attempt to determine the plan towards an advantage healthcare platform or to obtain any

financial gain or material profiting that has got defined in the custody of any health care help

program. Further fraud has become classified as a white collar form of the unlawful act where

filing of dishonest records gets done seeking profits from the funds realized.

On the other hand, abuse in the healthcare systems has seen the definition of the actions

that may directly or indirectly lead to unnecessary healthcare costs not excluding Medicare and

Medicaid programs. Additionally, it includes incorrect payment of healthcare products, payments

of unethically or services that have failed to reach the health standards and as well provision of

medically unnecessary services to patients (Winston, 2011).

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Ambulatory healthcare according to its definition proves to involve healthcare that does

not take into account admission of inpatients in hospital beds such as clinical and medical

consultancy. Accreditation can get analyzed as the certification that any organization receives on

meeting certain standards on the service provision for instance quality assurance approvals.

Care management has its basis from the prevention, treatment, and recovery of patients

with the illness. Cognitive services can get rated as the diagnostic facilities that a medical

practitioner offers during medical services provision, care and as well during consultations. The

commercial activities that a person conducts in his/her life towards economic and social

advantage. For instance nursing, consultancy and pharmaceutical services. Eligibility, on the

other hand, can get described as the worth or the approval that any worker possesses to qualify

towards offering individual services (Winston, 2011).

Background of the study

The society continues to remain in devastating health conditions despite the increased

funding and campaigns by the international community on eradication of diseases and as well

improvement of health care services. Although all the initiatives proved to worthy and working

in the society, little has become evidenced and as a result, I chose to investigate the causes of the

situation. The study will have its analysis towards discovering the means of public funds

consumption and as well the ethical standards of the health workers.

Statement of the problem

Deterioration of healthcare services has proved to become the order of the day and as a

result, studies to understand the cause become of importance. An inquiry into the reasoning,

implications, and measures to solve the challenge will have the study becoming significant.

HEALTHCARE FRAUD 5

Objectives of the study

To obtain the causes of health care fraud.

To seek knowledge on the implications of fraud

To analyze the types of fraud in the health care sector.

To offer an understanding and recommendations towards solutions and remedy on fraud

management in the healthcare industry.

Research questions

What are the causes of health care fraud?

What are some of the problems that get caused by fraud in the health care sector?

What are the types of fraud that exist in the healthcare industry?

How can the challenges get resolved?

Hypothesis

a -

health care has become a fraud-establishment both in the public and the private sector.

0 -

there have not been avenues of fraud in the health care industry.

Scopes of the study

The study will cover the health care industry with the primary aim of understanding fraud

in details and as well how it manifests itself in the wellness arena. Additionally, the study will

address some of the methods usable towards providing a solution to health challenges provoked

and established with the provision of fraud.

HEALTHCARE FRAUD 6

Literature review

According to FBI reports, proves that health care fraud continues to escalate and in turn

estimated to increase provided that people live longer in the society. Fraud not only increases in

the cost of health care but also endangers the lives of the patients as well as increasing the

chances of recording high revenues by the health care units. $808 billion spent on Medicare and

Medicaid by 2010 where an estimate of $1.5 trillion may prove a reality by the year 2020.

There appears to be a flaw in the health care systems regarding how things become

realized and as a result, the organizational weaknesses provide a chance towards fraud. For

example, the small proportion of fraud cases get detected and as a result, the professionals take

advantage of the weak systems (Onofaro, 2013).

Provider, consumer, and employee fraud remain to be some of the scams that take place

in the health care sector. Inadequate health care services have become a precipitating factor

towards health care fraud in that the consumers will seek to fraud to obtain the services.

Physician self-referrals to patients seek medical services in health care units that have their direct

advantage has also become popular. Ownership of private investments in the health care sector

by physicians provokes them to refer patients to their units so that they can reap profits. Fraud in

the healthcare units has seen the loss of information to criminals. For instance, AvMed Inc. lost

health records due to systems failure that led to a legal case that got lodged against them.

However, minimum payments also become an avenue that fraudsters use to commit fraud crimes

(Kongstvedt, 2012).

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Justification

Although other studies conducted towards understanding the issues underlying the health

care sector proved helpful, this study will invest must of its strength in understanding the causes,

implications and the measures that can get used to curb the practice. Additionally, the study gets

to prove its importance because it will offer a rationale behind the background and history that

warrants fraud.

Limitations of the study

The study will get limited to the health sector leaving the other segments of the society

unstudied. Also, it will seek to know the causes, implications, and remedies of the challenges

caused by fraud.

Conclusion

However, how much the results of fraud and abuse get felt measures to resolve them must

remain in place as well as deducing other means to combat the practice. Although some steps

have seen the light and practiced, further research and investigations to provide additional

measures must remain practical. Increased education and training can get used to curb the

practice and offer a remedy. The execution of computer-assisted coding as well as the use of data

modeling and mining tools will provide increased accuracy and monitoring of healthcare

systems.

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References

Kongstvedt, P. R. (2012). Essentials of managed health care. Jones & Bartlett Publishers.

Outterson, K. (2012). Punishing health care fraud—is the GSK settlement sufficient? New

England Journal of Medicine, 367(12), 1082-1085.

Onofaro, H. (2013). Lessons from Health Care Fraud Cases: Implications for Management of

Health Care Entities.

Winston, M. (2011). Health Care Fraud and Abuse.

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A study on the causes of healthcare fraud

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