Health Care Fraud in America – What’s the Truth is a guest article by Helen Bray
The numbers behind health care fraud mean it has to be taken seriously, by patients, hospitals, and law enforcement. According 
to the FBI, health care fraud (and abuse) costs the country billions of dollars each year. However you look at it, that accounts for staggering amounts of cash, even in a multi-trillion dollar health industry.
What constitutes fraud?
Fraud can take place by both patients and healthcare providers. In the patient’s case, this includes knowingly using another person’s insurance as their own or failing to remove a person who is no longer eligible to be on their insurance. By medical providers, the most common example of healthcare fraud is when a patient is given drugs or treatment they do not need. This allows the medical center to charge the insurance company much more than they should have been able to.
Who Wins?
In the world of health care fraud, everybody loses, including ultimately the fraudster. The billions of dollars that are lost in revenue through fraud isn’t just wiped from the system – it’s just made up in other ways. This means both patients and providers have to pay more each year than they should, just because of fraud.
Can Fraud Be Justified?
The short answer to this question is no. However, with health care fraud so widespread, it is worth considering why this should be the case. One reason is that it takes place because it’s possible to take place. The healthcare industry is very lucrative, and it is understandable how easily some people find to “bend the rules” to bump their profits.
For example, a health care professional may send a patient for an x-ray “just to be safe”, even when most doctors would find it unsuitable. This isn’t always obviously fraud – it’s just one doctor’s opinion, which is hard to legislate against. So while fraud can’t be justified, it might have to be a necessary evil if the healthcare system is going to carry on as it has been doing.
A Broken System
Even if every instance of fraud was a cut and dry case, it’s impossible to prevent under the current system. There will always be people who are willing to compromise their ethics in pursuit of the almighty dollar, and doctors are no different. The sheer scale of the problem shows that many people find the lure of a paycheck bump too much to resist. Consider this: you’re a doctor. A patient comes in. They’re fine, but you could make sure you’re triple-certain by sending them for an x-ray, which will also give your company a hefty bump from their insurers. What do you do?
I don’t think it’s as easy a decision as others make out. Obviously, some cases really are cut and dry – as in the case we wrote of recently of the doctors who billed dead people.
Patient Deceit: Does It Simply Have to Happen?
I’m sure people don’t want to lie and defraud other people. Some people, however, are pushed into it by circumstances beyond their control, such as financial worries, drug and alcohol problems, or emergency medical conditions. For a person who is worried they might die, it won’t take much to convince themselves that defrauding the hospital to receive the medical attention they need is the right thing to do. This line of thinking should perhaps make us go easy on those who lie; it may not be their fault that they’re in this situation (not everybody has insurance); they may be scared; and they may be really acting like themselves.
The current health care system does lend itself to be defrauded. For for-profit hospitals, the bottom line is how much money it makes. If they can do this by giving a patient extra drugs or tests, then inevitably some will. You can’t always expect an industry to voluntarily play by the rules. Similarly, there are reasons why patients defraud the system. For them, it’s less of a moral quandary; they’re not trying to get rich, they’re just trying to stay alive.
Perhaps to get to the root of cause, the entire healthcare industry has to come under the microscope and see if it really is as solid as it makes out. If people have to defraud, then it’s perhaps got some issues that need to be resolved.
Resources
https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud
http://www.acfe.com/article.aspx?id=4294974475
http://www.rehabs.com/pro-talk-articles/go-easy-on-the-liar-label-try-creating-safety-first/
http://health.costhelper.com/x-rays.html
http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
http://www.forbes.com/sites/danmunro/2012/01/19/u-s-healthcare-hits-3-trillion/
