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Health Care Fraud – The Perfect Storm

Health-care fraud is all over the news these days. Health-care fraud is undeniably rampant. The same may be said of any sentient business or person, such as banking, credit, insurance, politics, and so on. There is little doubt that healthcare practitioners who steal from us by abusing their power and our trust are a problem. Those in other professions who do the same are as well. When you look closer, you’ll notice that this isn’t a game of chance. Taxpayers, consumers, and providers are always losers because the problem with health care fraud isn’t just the fraud; it’s also how our government and insurers use the problem to push their own agendas while failing to be accountable and take responsibility for a fraud mistake they made.

1. Astronomical Cost Estimates

What better way to report on fraud than to boast about fraud cost estimates, such as those provided by the National Fraud Facility (NFIC)Fraud against both public health plans costs between $72 and $220 billion per year, driving up the cost of medical care and health insurance and eroding public faith in our health-care system… It is no longer a secret that fraud is one of the most quickly growing and costly kinds of crime today… These costs are borne by taxpayers and are reflected in higher health insurance rates… In order to address healthcare fraud and abuse, we must take preemptive measures… We must also ensure that law enforcement has the resources required to prevent, detect, and punish healthcare fraud. According to the Government Transparency Office (GAO), healthcare fraud costs between $60 billion and $600 billion per year, or between 3% and 10% of the $2 trillion healthcare budget. [Source: HealthCare Finance News, 10/2/09] The Budget Office (GAO) is Congress’s investigative arm.- According to the National Health Care Anti-Fraud Association (NHCAA), over $54 billion is stolen each year in scams designed to deceive us and our insurance companies. [http://www.nhcaa.org/] The Government Healthcare Association of America (NHCAA) was founded and is backed by health insurance companies. Unfortunately, the accuracy of the claimed figures is questionable at best. Insurers, state and federal authorities, and others may collect fraud data as part of their missions, with the type, quality, and body of data gathered varying greatly. David

2. Health Care Standards

The rules and rules regulating health care – that vary by state and payor – are complex and difficult to grasp for providers and others because they are written in legalese instead of plain English. Providers record conditions treated (ICD-9) and service delivered using specified codes (CPT-4 and HCPCS). When requesting reimbursement from payers for services provided to patients, these codes are used. Many insurers advise providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered – regardless of the fact that the codes were created to be widely true to promote correct reporting to reflect providers’ services. Furthermore, practice-based consultants train providers on what codes to report in order to be paid – codes that may or may not correctly reflect reality.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to address the problem in a consistent way with concrete initiatives that will result in the case of fraud claims before they are paid. Indeed, healthcare claim payors claim to operate a payment system based on trust that providers bill properly for care rendered because they can’t review every claim before payment because the reimbursement system would shut down if they did. They claim to use sophisticated computer software to look for errors and patterns in claims, to have increased pre-and post-payment audits of selected providers to detect fraud, and to have formed consortiums and task forces made up of criminal justice and insurance investigators to research the problem and share fraud data. However, the bulk of this activity is focused on

Conclusion

Those three beliefs, that healthcare reform will only affect the uninsured, that it will have no effect on Health care, and that ObamaCare will lower healthcare costs, are all false. It’s critical that you track what’s gone on with healthcare reform, since more changes are on the way as we move through this year, 2013. Knowing how to position yourself so that you’re in the greatest position to make the best rational choice at the beginning of 2014 will be critical for all.

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