The following research will also include recommendations for prevention of health care fraud, recommendations for change of structure, governance, and culture. The following research will include prevention measure for future situations involving health care fraud. Health care fraud is a preventable situation in hospitals across the nation. Hospitals spend thousands of dollars on quality assurance and patient safety and still health care fraud continues to occur. Individuals across the nation make a living through health care fraud. Honest, hard working citizens of this country are financing health care fraud recipients, not by choice.
Insurance companies, Medicare, and Medicaid are being schemed by fraudulent businesses. Channel 11 news in Colorado a scheme called, “Medical Provider Identity Theft” has been uncovered. Perpetrators stol the identity of a physician in Pueblo, Colorado. The perpetrators set up an office in Denver, Colorado called, “A Plus Billing. ” The office and address was used to receive mail and phone calls. The physician’s name and medical identification number was used to bill Medicare for test and procedures that were not preformed. This type of scheme is running rampant across the United States. Dr.
Cabiling did not know that his identity had been stolen until he received a phone call from Medicare. Medicare asked Dr. Cabiling if he practiced in Denver and Dr. Cabiling said, “No. ” Medicare then notified Dr. Cabililng that they had received bills from an office in Denver with his name and medical identification number for payment of services rendered. Dr. Cabiling only practices in Pueblo and not in Denver. Further investigation uncovered more than $1. 8 million dollars had been paid out to the A Plus Billing Company. “Court documents show the address A Plus Billing used was 600 17th Street in Denver, room 2800.
The company submitted bills for numerous things including MRI’s and EKG testing, claiming they had medical offices at that address. But instead, 11 News discovered it was home to a company hired to receive mail and answer the phone for $150 a month. And, according to records, the lady who was suppose to pay that bill, Aliya Valeeva, is no longer in the country. Medicare sent the money to an account at a BBVA/Compass Bank in Denver, under the name of A Plus Billing. Now the FBI has moved to seize nearly $800,000 of it (Potter, 2011). ” Dr.
Cabiling inadvertently received checks from Cigna, leading the physician to believe that the ghost company had targeted other insurance companies other than Medicare. Prior to President Obama’s health care reform, insurance companies were required to submit payment for services rendered within 15 days of receipt of the claim. Since President Obama's health care reform act the timeline for payment of services rendered gives agencies more time to make payments, review and investigate claims. Fraudulent claims are easier to detect with the new health care reform in affect.
Fraudulent claims are nothing new to insurance companies. Perpetrators have targeted insurance companies for a long time. Medicare and Medicaid are the two type of insurance companies targeted. Medicare and Medicaid staff is inundated with claims. There are more claims to be processed then there are staff and time. New timelines and guidances to follow, allow the staff to follow up on suspicious claims. Since the Affordable Health Care Act was passed and implemented “Medicare officials say with their new tools for fighting fraud, they have reclaimed $4 billion last year alone (Potter, 2011)”.
The previous organizational structure for payment of services rendered did not allow officials enough time to investigate claims to ensure the claims were legitimate. Perpetrators study the law and use the knowledge to fraud insurance and government agencies. The governance of rules, regulations and laws was not stringent enough to stop perpetrators from frauding the system. New guidelines allow agencies more time to detect suspicious claims, investigate and save the insurance companies millions of dollars. Society does not concentrate on proactive actions to prevent fraud, instead society deals with the problem after the fact.
Consumer watch groups do not have tools in place to prevent fraud. Perpetrators rely on the oversites of insurance companies in order to target and fraud insurance companies. Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud.
Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for proactively protecting personal information to prevent identity theft. The case of Dr. Cabiling could not have occured if his medical identity had not been stolen. A closer watch of personal information to prevent identity theft is the beginning to prevent health care fraud. The federal government should have in place the ability to prosecute offenders to the fullest extent.
Harsh punishment may deter offenders from comiting the offence. Ethical issues concerning medical fraud is as simple as knowing what is right and what is wrong. Society should take responsibility of his or her own personal information. Identity theft is no secret, therefore society should be more proactive. Do not leave an open door for offenders to walk in and take what does not belong them. The laws for offenders should be more stringent. The current structure of physicans medical information is too easy to obtain.
The structure of physicains medical information should be in encripted messages making the degree of difficulty high enough to ward off offenders. There are some offenders that will stop at nothing until they have gotten the information he or she is wishes to obtain. Stricter rules and guidelines can ward off these offenders. Governance over the guidelines for payment for services rendered should include the following; varification of physician’s medical information making sure the physican is aware of the charges being submitted to insurance companies.
The time line for payments to be released to physicians or billing companies are lenghtened to allow incurance companies time to investigate suspecious claims. The culture of one waiting for another to do what is right is an occurance needing change. The culture can be changed through leading by example. Educating society through public service announcement is a start. Public service announcements reach more people than emails, newspaper articles, and phoone calls. An aggressive campaign to stamp out medical fraud through prosecuting identity theft offenders is an additional way to combat medical fraud.
Through public service announcements society is informed of his or her responsibility to protect personal information to prevent identity theft and medical fraud. Fighting identiy theft and medical fraud cost less than the billions of dollars paid out to offenders. Remind society they the communities in which he or she live in are the one that ultimately pay the price through higher health care premiums, higher prices for health care services, and through higher taxes. In conclusion health care fraud is now being done through identity theft.
Identity theft can be combatted through public awareness and the public taking responsibility to protect his or her own persoanl information. Dr. Cabiling through no fault of his own was a victim of identity theft. Dr. Cabiling did not know that his medical identity had been stolen until he received a phone call from Medicare. Dr. Cabiling can now contact the different insurance companies to alert them of the fraudulant activities concerning his medical information. The insurance companies can contact Dr. Cabiling prior to making payments on calims. The insurance companies making phone calls to Dr.
Cabiling may take more time, but will save the companies money in the long run. Combatting medical fraud and identity theft is everyone’s responsibility. References Cohen, G. (2010, March/April). Medical tourism: The view from ten thousand feet. Hastings Center Report, 40(2), 11. Health care reform to have impact on ethics. (2010, May). Medical Ethics Advisor, 26(5), 54. K. Potter, 2011. Medicare Fraud Scheme Takes Nearly $2 Million, Pueblo Doctor’s Identity Stolen; http://www. kktv. com/home/headlines/Medicare_Fraud_Scheme_Steals_Millions_131567818. html