Healthcare Fraud Overview
Approximately 2.26 trillion was spent on healthcare in 2008. The National Heath Care Anti-fraud Association conservatively estimates that at least three percent of this figure is lost to fraud—or $68 billion. Healthcare fraud translates to higher health insurance premiums, higher taxes, and higher co-payments.
Patients have been harmed as a result of fraudulent activities involving medical transportation, surgeries, invasive testing, and certain drug therapies. (For example, a pharmacist was convicted for diluting cancer drugs purely to increase profits; and surgeons performing unnecessary surgery to increase profits). Patients and their insurance information are being exploited in ways that are new and sometimes harmful.
Healthcare fraud is a federal crime, as well as, a crime under most state criminal codes. State legislators continue to enhance their regulatory oversight to address areas vulnerable to fraud and abuse. Some states require health insurers to meet certain fraud-related preparedness standards and thousands of dishonest and un-credentialed providers have lost their medical license to practice.
What is Fraud and Abuse?
Healthcare fraud is:
- The intentional or deliberate submission or filing of false claims for the purpose of illicit gain;
- Lying about your condition or the types of services provided;
- Cheating by omitting information about your condition, symptoms, or the treatment or services received; and
- Stealing.
Abuse is:
- Similar activity, but where intent or deceit cannot be established.
Who Commits Healthcare Fraud?
- Individual patients;
- Physicians and other practitioners;
- Pharmacists;
- Nurses;
- Laboratories;
- Billing services;
- Medical equipment suppliers;
- Hospitals;
- Nursing homes; and
- Employees of healthcare providers and insurers.
This does not mean that large numbers of healthcare professionals and others involved in the healthcare system are dishonest--the vast majority are honest and ethical and affected by healthcare fraud in the same way that most Americans are victimized.
Some Common Healthcare Fraud Activities
- Claims from phantom or fictitious providers;
- Claims for services or supplies never provided; and
- Altering documents used to obtain payment.
