Healthcare Fraud

Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go a long ways in the overall crackdown of health care fraud.

The Federal Bureau of Investigation is spending large amounts of its budget to crack down on health care fraud. Special units have been formed to help the FBI Crimes Section find these criminals and take them to court to seek proper punishment. Crimes are being committed by both providers and insurance companies on a daily basis. Moreover, their patients and subscribers are being punished with improper coverage and over-priced procedures and prescriptions. The FBI is one of the leading organizations in the fight against health care fraud. The Health Care Fraud Unit was established in 1992 to insure the success of investigations which have a national impact on the health care fraud crime problem. Furthermore, their mission is to concentrate their investigative resources on multi-district investigations of large health care providers that are being sought out for fraud against both public and private payers of health benefits. The FBI coordinates their efforts with other law enforcement agencies and regulatory agencies. Some of the regulatory agencies that they work with include the Department of Health and Human Services Office of the Inspector General (HHS-OIG) and the Health Care Financing Administration, which is in charge of both the Medicare and Medicaid programs. Despite the power of the Health Care Fraud Unit, no investigations are actually conducted by this unit. Its primary function is to assist and provide guidance to field offices (About The Health Care Fraud Unit 1).

The creation of this unit was in response to extreme losses due to health care fraud. In 1999, annual health care expenditures in the U.S. totaled nearly $1.1 trillion and it is estimated that as much as ten percent of that total is fraudulent. An overwhelming number of the fifty-six FBI field offices rate health care fraud as their number one white collar crime problem. The FBI has been able to secure more resources for more agents due to the funding received as a result of the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). With HIPAA enacted, federal laws now state that if a perpetrator’s fraud results in more injury to a patient, they could be entitled to a doubling of their prison term (up to 20 years). Moreover, if the patient loses their life as a result of fraud, the perpetrators could be subject to life in prison. In response to federal mandates, states also have increased their punishments for such fraudulent activities and they now are regulating providers and insurers themselves (Health Care Fraud 1). The FBI can not measure the success of the program by the number of yearly convictions, yet they look at the deterrent effect that their efforts have on those who may be considering fraud. Medicare also contributed lower than expected spending last year to the effects of the taskforce (About The Health Care Fraud Unit 1). The government has estimated that on average about 44 percent of the overall fraud targets Medicare and Medicaid (Health Care Fraud Video Text).

Health care fraud is noted as the deliberate submittal of false claims to private health insurance plans and/or tax funded health insurance programs such as Medicare and Medicaid. In the year 2000, nearly $1.3 trillion was spent on health care and related fields. With all of that spending, how much of it was really legit and how many times were extra charges added on in an attempt to take advantage of a patient and their insurance company? Doctors and surgeons are now marketing their services to potential patients in order to get as much work and in turn money as possible. Yet, with all of this positive marketing for new surgical procedures, the lack of knowledge of potential patients is being taken advantage of on a routine basis. Hospital administrators are now trying to find more ways to get their physicians to get more work in order to add to the hospital’s bottom line. Physicians are feeling the pressure from management to get as much work done as possible and they are burning themselves out (Health Care Fraud 1).

The Federal Trade Commission and the Food and Drug Administration have advised people that they could be prime targets of health care fraud if they have one or more of the following conditions: cancer, AIDS, arthritis, multiple sclerosis, diabetes and Alzheimer’s disease. People