Fraud occurs when an individual is intentionally deceiving a party for personal or financial gain. Fraud is a nonviolent type of crime and is usually committed by business professionals, hence a white-collar crime. This type of crime has been in existing for a long time even in sectors as sensitive as the healthcare sector, only that it is hidden.
There are different types of healthcare fraud done by various people to different victims, but in most cases, it involves medical professionals attempting to steal funds from healthcare insurance companies. For example, a patient can go for a checkup with the doctor, which is covered by health insurance where he is subjected to different tests. Later on, the patient receives an explanation of benefits through a mail that lists all the insurance company’s services he has consumed only for such a patient to realize that the most or some of the procedures listed were not performed during the visit.
The Law is there, but it is inadequate to solving this problem
The law states that anyone who intentionally submits a false claim is liable for penalties up to three times the damage incurred. However, some doctors still perform medically unnecessary tests or procedures to bill the insurance company and collect the funds.
Bribery is also a federal white-collar crime, and it is also being involved in healthcare fraud. According to Gregory Pimstone of Manatt, a medical lawyer from America, a doctor can refer patients to a particular specialist with whom the doctor agrees and receives kickbacks, in exchange for the referrals.
Other medical providers involve their patients in fraud schemes by waiving co-pays for the patients or only required patients to pay in-network amounts. Then the providers charge the insurance company a much more significant amount. Since the patients are involved, they are rendered powerless and cannot report such cases to the insurance company.
The government has come out to bring to a stop this kind of crime. Still, the efforts it is putting are somehow inadequate. This is because it involves professionals who understand the law and carefully define methods to maneuver through them with ease. Nevertheless, the perpetrators are highly trusted professionals who are seen by many as helping people, and the patients mainly care about their healing. Pimstone suggests that a good understanding of the methodologies they employ, it is possible to craft a method that will significantly reduce this fraud by encouraging whistle-blowing.