Fraud and Abuse
Fraud and abuse in the healthcare sector include the acts of healthcare providers that are deemed to have defrauded the healthcare facilities, and government or abused the right to bill for services rendered. However, the distinction between fraud and abuse is never clear. The degree of intent by the individual or entity under investigation is often the determining factor. Healthcare fraud and abuse are criminal acts, which are characterized by filling of dishonest healthcare claims to achieve a profit. Fraud is an occurrence where healthcare providers intentionally deceived Medicare, whereas abuse is when clinicians do not follow the instructions, which they are required to follow (Drabiak & Wolfson, 2020). These cases may result into improper billing and unnecessary costs. Therefore, it is the responsibility of healthcare providers to behave ethically and improve the billing process. Clinicians are also required to implement comprehensive programs that can assist in detecting and preventing fraud and abuse. Such cases have cost the health industry billions of dollars.
Fraud is defined as a process where healthcare providers knowingly and willfully execute, or attempt to engage in such practices to defraud a healthcare benefit program. However, healthcare professionals may obtain through a means of false or fraudulent pretenses, representations, as well as promises of any money or property owned by a healthcare facility. At the same time, healthcare personnel may also obtain assets or resources under the custody or control of any healthcare benefit program (Drabiak & Wolfson, 2020). Most healthcare professionals are honest and work hard to improve the health of their patients. Some nurses and other healthcare personnel may want to reap financial benefits from fraudulent acts. Financial losses due to healthcare fraud are in billions of dollars, which affects the healthcare sector. Individual victims of healthcare fraud are easy to identify in the healthcare facilities. The increased expense from fraud means that there is a major difference between ensuring that healthcare insurance is a reality or not.
Examples of Fraud
There are several examples of fraud in the healthcare facilities. For instance, healthcare providers may bill for services that are not provided to gain profit. Other healthcare professionals may bill for services that are performed by others. In some cases, clinicians may use incorrect or inappropriate provider number for them to be paid (Drabiak & Wolfson, 2020). Also, some physicians may sell or share their clients Medicare numbers. The other way to engage in fraud is to provide falsifying information on the patients’ medical records, billing statements, and other financial records to the government.
In the healthcare setting, abuse may directly or indirectly result in unnecessary costs to a program such as Medicare or Medicaid, improper payment, or payment for services that fail to meet professionally recognized standards of care or that are medically unnecessary. Typically, the physician or other health care professional may knowingly and willfully misrepresent facts to obtain payment. The performance of services considered by the carrier to be medically unnecessary, and my led to poor patient outcome (Ahadiat & Gomaa, 2018). Also, this may result into the failure to document the patient’s medical records adequately. Other cause of abuse may be unintentional, inappropriate billing practices, such as misuse of the modifiers. Other causes of Medicare limiting charge violations as well as failure to comply with a participation agreement. Furthermore, abuse may occur due to inadvertent of duplicate claims.
Healthcare Principles that May Arise when Facing the Situation
Fraud and abuse may cause harm that worsens patient conditions. In addition, fraud and abuse cause healthcare providers to engage in improper financial relationships, which is not ethical. The cases may also lead to the violation of the False Claim Act, which guides nurses at the workplace (Drabiak & Wolfson, 2020). The payment made illegally may represent the levels of services offered, which worsens patient conditions.
The HIPAA has been at the forefront to add substantial funding programs for fraud and abuse activities for several of the agencies concerned with fraud and abuse in the healthcare sector. Besides, most of the funding activities allowed for the hiring of additional investigators as well as other law enforcement personnel. HIPPA increases penalties for fraud and abuse and also provides incentives that are payable to informants. HIPAA authorizes the department of HHS to offer Medicare beneficiary with rewards or rewards to report any fraudulent practices.
Ahadiat, N., & Gomaa, M. (2018). Healthcare fraud and abuse: an investigation of the nature and most common schemes. Journal of Forensic and Investigative Accounting, 10(3), 428-435.
Drabiak, K., & Wolfson, J. (2020). What should health care organizations do to reduce billing fraud and abuse. AMA journal of ethics, 22(3), 221-231.