HEALTHCARE FRAUD

Healthcare Fraud in United States

Abstract

In this study, we try to explore the concept of “Fraud and Abuse in Healthcare System in United States" in a holistic context. The main focus of the research is on “Fraud and Abuse” and what are the problems that this major issue is creating and most importantly how to combat this issue. The research also analyzes many aspects and different types of fraud and abuses in the healthcare system and tries to gauge its effect on the credibility of United States healthcare system.

Table of Contents

Introduction4

History and Trends5

Healthcare Fraud5

Discussion5

Suggested Techniques of Detecting & Preventing Fraud7

Dynamic Rules Engines8

Government Involvement8

Current Trends Related To Ethics and Decision Making9

Conclusion10

References11

Healthcare Fraud in United States

Introduction

We are all aware that there has been an increase in Health Fraud and Abuse over the last several decades. We are also aware that there has been an increased interest by the federal government to fight the rising incidence of fraud and abuse in America. In 1989 The National Healthcare Antifraud and Abuse Association estimated the United States spent $590 billion on healthcare and that 10 percent, perhaps as much as 25 percent were unnecessary costs associated with fraud and abuse. That is a range of approximately 60 to 150 billion dollars attributed to fraud and abuse (Henderson, 2011). Today the Health and Human Services (HHS) Office of the Inspector General (OIG) projected that fraud and abuse accounts for between 3 and 15 percent of expenditures for healthcare in the United States. Other agencies, such as The National Healthcare and Antifraud Association Report, the Congressional Budget Office, and the US Chamber of Commerce suggest that fraud and abuse costs range between 3-10 percent, 10 percent, and 15 percent respectively. According to this data, the annual estimated cost of healthcare fraud and abuse ranges between $100-170 billion in America (Ettinger, 2008).

It is the industry that constitutes 15% of the overall economy of U.S and is considered as one of the largest and best healthcare industry all over the world. When any industry operates on such a huge level and involves more of the private entities rather than the government, it is likely to get affected from malpractices of different sorts of frauds and abuses. This paper discusses fraud and abuses in United States healthcare industry its impact on overall industry and how to deal with this issue (Sparrow, 1994).

History and Trends

Healthcare Fraud

We have heard about fraud in partnership, fraud in accounting and fraud in the banking industry. Fraud in all these fields is very common but now even the healthcare industry is not safe from it. Fraud has accessed healthcare industry. Now the question arises how one can do fraud in the healthcare system and the answer to that question covers a broad horizon.

Fraud in the healthcare system can be done in more than one ways. This fraud can be done from both side means from the patient's end as well as from the healthcare service provider's end. This fraud can be of any ...