Health care fraud is an increasingly prevalent threat that costs the entire country tens of billions of dollars annually. As a more and more common event, more Americans than ever have been victimized as a result of healthcare fraud. Recent events also confirm that medical professionals may be more willing to risk the threat of patient harm in order to advantage or further their own schemes (“Health,” 2010). Healthcare fraud not only costs the nation steep expenses every year, they also endanger the lives of Americans. Every year, there are several million health insurance claims submitted to health insurances, which make healthcare affordable. However, a fraction of these millions are indeed fraudulent, but this fraction costs all Americans and the government, consequently, with tens of billions of dollars yearly, which result in even higher premiums and additional out-of-pocket expenses for Americans (“Healthcare,” 2012). There are several types of insurance frauds that occur in America, but medical insurance fraud and Medicare/Medicaid insurance fraud constitute the majority of fraud in America, thus illustrating the significance of this issue (“Healthcare,” 2012).
Healthcare fraud can arise in a variety of situations, which may range from duplicate tests and procedures, to unnecessary tests, to hacking into patient’s personal medical records to submit false claims. However, according to the National Health Care Anti-Fraud Association, or NHCAA, the most prevalent types of fraud are limited to just a handful (“The Challenge,” 2015). For example, performing medically unnecessary services for the sole purpose of generating insurance payments, taking kickbacks for patient referrals, and billing for services that never actually occurred. This billing can occur either through using actual patient information (via identity theft), or falsifying entire claims with additional charges for procedures or services that never occurred (“Healthcare,” 2012).
Additionally, healthcare fraud can occur when healthcare providers bill for more expensive services than were actually performed, known as “upcoding” (“Healthcare,” 2012). Unbundling can also occur, in which each step of a procedure is billed. Misrepresenting non-covered treatments as medically necessary for the sole purpose of obtaining insurance payments (i.e. nose jobs which are billed as deviated septum repairs) is another kind of healthcare fraud. Another common example is when patient-co-pays are waived, or deductibles, and then over-billing the insurance carrier. Lastly, billing a patient for more than the co-pay amount for services that was prepaid or paid in full by the person’s plan is also a form of healthcare fraud (“Healthcare,” 2012).
The impacts of healthcare fraud are extensive, to say the least. As stated previously, the NHCAA estimates that the financial expenses associated with healthcare fraud result in the tens of billions of dollars annually (“The Challenge,” 2015). Whether an individual has employer sponsored health insurance, or his or her own policy, healthcare fraud results in higher premiums, more out-of-pocket expenses, and diminished coverage and/or benefits for insured Americans. For employers-private and government healthcare policies, fraud leads to a higher cost of providing insurance benefits to employees, which also increases the total expense of conducting business. For many Americans, the increased expenses that result from healthcare fraud can determine whether they receive health insurance or not (“The Challenge,” 2015).
As significant as financial losses are as a result of healthcare fraud, there is another loss that occurs with concern to the individual victims of healthcare fraud. Often, these are individuals who have been subjected to or exploited by quite unsafe or unnecessary medical practices and/or procedures. They may be individuals whose medical records have been compromised, or those who have legitimate insurance information that is used to submit false claims for others (“Healthcare,” 2012). In this way, healthcare fraud is not a victimless crime, and produces devastating effects both financially and personally in the lives of many Americans.
The Health Insurance Portability and Accountability Act, or HIPAA, in addition to national Coordinated Fraud and Abuse Control Program, work together to help control the laws and ramifications for those who violate health care insurance claims and policies. According to HIPAA, healthcare fraud and abuse constitutes a federal criminal offense with weighty penalties. Those who are found guilty can face up to 10 years in prison, along with hefty fines. Additionally, if a patient has been injured as a result of healthcare fraud, the sentence can be doubled, and if the patient has died, the convicted can be sentenced to life (“The Challenge,” 2015).
The principal of healthcare services, whether it is fraudulent or not, is closely related to the core value of integrity. Integrity can be defined in a number of ways. Integrity, for the most part, means performing actions and behaving in an ethical/moral way, even when alone. Healthcare fraud violates this core value, as it is a highly unethical practice that violates the safety of others’ personal information, or even violates/endangers their health and life. A single individual or a group of individuals can perform healthcare fraud. This can consequently affect any number of persons that are honestly and ethically paying for their healthcare coverage. In essence, healthcare fraud violates the core value of integrity, as it comes at the cost of compromising others.
In conclusion, healthcare fraud occurs in a number of ways as a result of unethical measures performed by professional healthcare providers. This can lead to a host of damaging effects not only for the individuals affected, but also the nation, as healthcare fraud costs the entire country tens of millions of dollars every year. Ultimately, healthcare fraud violates the core value of integrity, as it detrimentally compromises others.
- Healthcare Fraud. (2012, January 27). Retrieved December 11, 2015, from http://www.healthcarebusinesstech.com/healthcare-fraud/
- Health Care Fraud. (2010, April 16). Retrieved December 11, 2015, from https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud
- The Challenge of Health Care Fraud. (2015). Retrieved December 11, 2015, from http://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-f raud.aspx