PatientsMedical professionalsContractors
- Fraudulent provision of sickness certificates
- Prescription fraud
- Evasion of medical charges
- Prescription fraud by pharmacists
- Fraud and error concerning payments for medical tests, facility services, and consultations
- Fraud and error related to long term care, home and community-based services, foster and child care
- Insurance fraud
In their report, the problem of healthcare loss analysis saw a global average loss rate of 6.19% as a proportion of global health care expenditure. Under these conditions, any health care organization and any area of expenditure could see losses of at least 3%, probably more than 5%, and, in more extreme cases, well over 10%.
Identifying health insurance fraud
- Performing medically unnecessary surgeries or treatments to generate higher insurance payments
- Accepting kickbacks for patient referrals
- Falsifying of tests to justify unnecessary medical actions
- Billing insurers for services that were not rendered, or padding claims with charges for procedures that did not take place
- Upcoding, which is the act of billing for more expensive services or procedures than were actually performed
- Unbundling, which is the act of billing each step of a procedure as an individual procedure
- Misrepresenting non-covered treatments
- Waiving patient payments (co-pays or deductibles) and charging these costs to the insurer or benefit plan
- Billing a patient for more than their co-pay or deductible amount
Patients and insured individuals are more simple in their fraudulent actions. Many cases of patient fraud simply involve undisclosed pre-existing conditions, or being dishonest about the nature and extent of an injury in order to receive higher insurance payouts. Indeed, cases of completely fabricated claims, and physician-shopping to obtain multiple prescriptions are also common; all of which simply exacerbates the challenge the sector has in stamping out corrupt practices.
The hidden costs of medical fraud
Overburdening the health care system
Identity theft
Physical or lethal harm to patients
Increasing health insurance premiums
For private insurers, however, fraud losses are instead levied amongst consumers. Insurance companies are risk managers. If trends indicate that fraudulent activities are becoming more frequent or bolder, you can expect the insurance premiums will be adjusted in order to soften the blow these incidents can inflict on their shareholders. They are, after all, businesses. One of the biggest barriers to maintaining premium stability for many insurers is that methods for measuring, identifying, and understanding just how much fraud is accurately being carried out; for example, PKF and the University of Portsmouth suggest that low-value fraud is common, while large-scale examples are fairly unusual.
What can I do to help combat fraud in the health care system?
- Keep your health insurance and personal information protected.
- Be informed about your role as a patient or insurance consumer, and don't be afraid to question your health care provider about procedures or billing items you don't understand.
- Seek out an independent opinion about treatments or care if you need it.
- Be responsible for your own health care and treatment, and seek services from an appropriate source.
- Report fraud if you come across it.
Further to ensuring you're empowered and protected personally, also think about your influence on the health sector from a social standpoint. The three biggest factors related to fraud are:
- Poverty;
- Poor health regulation; and
- A lack of transparency.
If you can, try to influence the policymakers in your country to ensure that the health sector is well supported in their fight to keep health care system and insurance fraud down.
