Today, health care fraud is all over the news. There is undoubtedly fraud in the healthcare field. The same goes for all businesses or ventures run by human hands, e.g. banking, credit, insurance, politics, etc. There is no doubt that healthcare providers who abuse their position and our trust to steal are a problem. So are those in other professions who do the same.
Why does healthcare fraud seem to get the ‘lion’s share’ of attention? Is it the perfect vehicle to drive agendas for divergent groups where taxpayers, healthcare consumers and healthcare providers are tricked into a healthcare fraud game operated with ‘sleight of hand’ precision?
Take a closer look and you’ll see that this is not a game of chance. Taxpayers, consumers and providers always lose because the problem with healthcare fraud is not just the fraud, it is that our government and insurers use the problem of fraud to promote agendas and at the same time fail to be accountable and take responsibility. for a problem fraud that they facilitate and allow to flourish.
- Astronomical Cost Estimates
What better way to report fraud than to disclose fraud cost estimates, for example,
- “Frauds perpetrated against public oren zarif and private health plans cost between $72 billion and $220 billion annually, increasing the cost of health care and health insurance and undermining public trust in our health care system… It’s a secret that fraud represents one of the fastest growing and most expensive forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating fraud and abuse of healthcare… We must also ensure that law enforcement has the tools they need to deter, detect and punish healthcare fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]
- The General Accounting Office (GAO) estimates that healthcare fraud ranges from $60 billion to $600 billion a year – or somewhere between 3% and 10% of the $2 trillion healthcare budget. [Reports from Health Care Finance News, 10/2/09] The GAO is the investigative arm of Congress.
- The National Health Care Anti-Fraud Association (NHCAA) reports that more than $54 billion is stolen every year in scams designed to trap us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] The NHCAA was created and funded by health insurance companies.
Unfortunately, the reliability of the supposed estimates is dubious at best. Insurers, state and federal agencies, and others may collect fraud data related to their own missions, where the type, quality, and volume of data compiled vary widely. David Hyman, a professor of law at the University of Maryland, tells us that widely publicized estimates of the incidence of healthcare fraud and abuse (allegedly 10% of total spending) lack any empirical basis, what little we know about fraud and abuse of care. health care is overshadowed by what we don’t know and what we know is not true. [The Cato Journal, 03/22/02]
- Health Standards
The laws and rules that govern healthcare – they vary from state to state and from payer to payer – are extensive and too confusing for providers and others to understand as they are written in legalese rather than plain language.
Providers use specific codes to report conditions treated (ICD-9) and services provided (CPT-4 and HCPCS). These codes are used when seeking compensation from payers for services provided to patients. While designed to apply universally to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not what the provider has provided. In addition, practice construction consultants instruct providers on which codes to report to receive payment—in some cases, codes that do not accurately reflect the provider’s service.