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As the health care Industry became one of the profit spinning industries it started attracting all kinds of players including criminals who perpetrated huge frauds on the innocent victims. The health care frauds are on the scene with its full magnitude only during the last two decades in the United States.

This paper looks at health care fraud and the impact that it is currently having on the delivery and reimbursement of services provided. The objective of this paper is to bring into light the kinds of diseases being targeted by the fraud perpetrators and the targeted customer groups. The paper has also related some case studies to impress upon the actual dimensions of healthcare frauds.

The other objective of the paper is to educate the readers about the means of identifying the existence of such frauds and also the ways to keep themselves away from them. In the process of dealing the health care frauds extensively, the role of FBI’s Health Care Fraud Unit in dealing with these crimes and the potential benefits that may be emerge to the people of US due to the actions of the FBI is also dealt with by the paper. In a nutshell this paper envisages that the health care fraud is of a substantial magnitude and it is possible to contain it with proper and concerted efforts and practices.

Introduction:

“Whether they’re looking for a short cut to losing weight or a cure for a serious ailment, consumers may be spending billions of dollars a year on unproven, fraudulently marketed, often useless health-related products, devices and treatments”. This is due to the reason that ‘health trades on false hope’[i].

The medical professionals like doctors and surgeons are in the process o marketing their service in order to keep them busy all the times and at the same time to fleece the patients of hefty sums as professional fees.

Despite the vigorous marketing of the up to date medial services by thee professionals, the innocence of the patients is taken to their advantage by the health care fraudsters on a routine basis. In addition the hospital administrators are pushing the physicians and surgeons in their rolls to get more patients and thereby to increase the bottom line of the hospital organization.

Because of this excessive pressure from their managements the physicians are over pressured and they are ‘burning themselves out’.

The Federal Bureau of Investigation is spending large amounts of its budget to crack down the health care frauds.  Special units have been formed to help the FBI Crimes Section to nab these criminals and present them before courts of law to get them proper punishments. Heath care fraud of a criminal nature is being committed by both the providers and insurance companies every day.

Moreover, their patients and subscribers are subjected to the dishonest deeds of improper coverage and over-priced procedures and prescriptions which may lead to further complications in some cases as these prescriptions are made without proper diagnosis.

This paper envisages apprising the reader that they are the targets of providers and insurance companies, and with a little knowledge about the modus operandi of these fraudulent groups, they can protect themselves from any kind of health care frauds.

While the paper will provide some case studies in the medical profession which go to prove what kinds of frauds can be perpetrated in the health care sector, it also enumerates some examples of the ways by which ignorant people are made the victims of these unscrupulous activities. This will enable the readers to safeguard themselves from exposure to these frauds.

The main objective of the paper is to establish that the health care fraud is a significant issue and cannot be ignored without seriously addressing it.

What is Health Care Fraud?

The different kinds of health care frauds include kickbacks, claims for services that were never provided, claims for the equipments which were not required and producing bills for services rendered by a person of inferior qualification.

The perpetrators of these kinds of frauds are found in almost all the constituents and agencies related to health care industry like hospitals, nursing homes ambulance services, all kinds of medical practitioners, testing agencies and medial stores. All violations are subject to the penal provisions of the applicable legislations.[ii]

In accordance with the above definition of health care frauds the following acts shall be deemed as health care frauds:

  • Altered or fabricated medical bills and other documents.
  • Excessive or unnecessary treatments.

Billing schemes, such as:

  • charging for a service more expensive than the one provided
  • charging for services that were not provided
  • duplicate charges

False or exaggerated medical disability. Collecting on multiple policies for the same illness or injury.” (Ohio Lemon Law)

The present health care fraud schemes include cancer drugs which are diluted and lab tests conducted with fraudulent intentions. There are surgery centers which are unscrupulous that lure and put on rolls individuals who possess quality insurance coverage.

These individuals are often provided covered surgeries in exchange for kickbacks and the surgery centers collect hefty sums from the insurance companies. The schemes also involve patients who as a part of the illegal  schemes are willing to undergo unnecessary and unwarranted medical routines and lab tests to generate fraudulent claims and make large profits there of. (Ohio Lemon Law)

Thus health care fraud can take the form of a deliberate submittal of false claims to private health insurance plans and/or tax funded health insurance programs such as Medicare and Medicaid.  It may be noted that in the year 2000, the total spending on the healthcare and the related fields was nearly $1.3 trillion.

It will be really shocking to find the proportions of amounts spent on legitimate issues and in fraudulent ways to take advantage of the ignorance of common people and their insurers.

‘Fraud’ is a serious crime and punishable offence, which fact should be well understood and appreciated by all the constituents of the health care system in the United States and it is also true that the fraud in the health care industry is an expensive reality, the effects of which cannot be undermined by the government of the United States

  1. “Miracle Health Claims:  Add a Dose of Skepticism.”  Food and Drug Administration Sept. 2001.< http://www.ftc.gov/bcp/online/pubs/health/frdheal.htm>
  2. “Health Care Fraud:  A Serious and Costly Reality for All Americans.”  National Health Care Anti-Fraud Association.  25 Oct. 2004.  <www.nhcaa.org/pdf/all_about_hef.pdf>
  3. Ohio Lemon Law ‘Health Care Fraud’ <http://www.ohiolemonlaw.com/health-care-fraud-victim.html>

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