healthcare fraud
Fraud remains to be a significant issue affecting the healthcare system because of the impact they have on both public and private healthcare systems. Healthcare fraud is not a new issue but a problem that has always been there and stemming from both the healthcare providers and the patients as well. Healthcare fraud can be defined as an occurrence where a person offers false facts associated with healthcare services to increase or receive payment from a given health plan. This also occurs when someone gives false details associated with care services or supplies. Healthcare abuse, on the other hand, is what happens when there is an activity that abuses the healthcare system, but at the same time, it does not meet the definition of fraud or rather is not medically necessary. The key difference between the two lies in the capacity to prove intent.
One of the forms of healthcare fraud is when billing for services is not performed. Any service that has been offered to the clients must be accounted for, as this helps in the management of care services. However, when the care provider fails to bill the services offered, then this creates a deficiency in the utilization of the resource, thus affecting cost management. The other form of healthcare fraud is the misrepresentation of the offered services or performed procedures with the intention of obtaining payment for services not covered. This occurs when the hospital or practitioner adds extra services and procedures to the list of what the institution has incurred so that the insurance company or the patient pays for more than that which is deserved. As a result, the care provider ends up pocketing more than necessary and thus making an unworthy profit.
One form of healthcare abuse is ordering more tests than those that are medically required for a given medical condition. An example of where this would occur is when the patient only needs to be tested for fever, but the doctor recommends that the patient is also tested for pneumonia. One of the main reasons why this would occur is the need to make the patient or insurance system pay for more than is necessary; hence extorting money from the payers. The other form of healthcare abuse is the alteration of specific procedure codes and unbundling of services that are usually delivered together with the intention of increasing payment.