MEDICAL CRIME

Crimes in the Medical Profession

Abstract

Crime in the medical profession is an important and visible factor associated with increasing health care costs in the United States. Medicare and Medicaid contribute to a vast majority of those costs and therefore must be heavily scrutinized. This paper will investigate the types of crimes and frauds, who commits them, and why the health care system is more susceptible to crimes. More specifically, the problems and complications of current crime investigation for Medicare and Medicaid are examined. This paper will then evaluate how successful these initiatives were in reducing health care fraud and explore new suggestions for preventing health care fraud in the future.

Table of Contents

Abstract2

Introduction4

Background4

Medical Crime/Fraud Defined5

Criminal Techniques and Who Commits Them6

Phantom Billing6

Bogus Billing7

Unnecessary Services7

The Problem: Medical Crimes Within Medicare/Medicaid8

Government Organizations Responding to Health Care Crimes9

Conclusion9

References12

Crimes in the Medical Profession

Introduction

Crimes in the medical profession are an important and visible factor associated with increasing health care costs, because there is no positive side to it. Some of the other factors that increase costs, such as better technology, have positive implications, but health care crime is only viewed as a drain on health care resources. Medical crimes and abuse costs the United States an estimated 110 billion dollars a year (Caldwell, 1997). Because medical crime has played such a vital role in increasing the cost of health care it has gained a lot of attention from the government and the United States people. In the 1990's the Clinton administration began a health care reform campaign and focused a lot of resources on stopping and, furthermore, preventing health care fraud within the Medicare and Medicaid programs.

Background

Since the 1960's health care costs have risen from 28 billion dollars per year to an estimated 1.9 trillion dollars per year in 2004 (Snapshot, 2006). That rise in cost accounts for an average of 6,300 dollars per person per year spent on health care, compared to 3,600 dollars per person per year in 1994 (Snapshot, 2006).

This substantial increase in cost causes a problem for most Americans because average income has not increased as steadily as health care costs, leaving many Americans unable to afford or access health care (Effect, 2007; Snapshot, 2006). The “health care cost inflation invariably exceeds growth in the economy as a whole” (Sage, 1999). Many factors have contributed to the dramatic increase in health care costs such as a cultural preference to focus on expensive treatment instead of preventative measures, technological advances, the ability to live longer thus using more resources, medical malpractice, and healthcare fraud.

Medical Crime/Fraud Defined

Out of all of the factors mentioned above, Americans believe crimes in the medical profession are the most significant reason for the rise in health care costs (What, 1997). It is clear to see why Americans consider this the biggest cause, when medical crimes were estimated to cost approximately $100 billion to $250 billion per year in 1998, or 10 percent to 25 percent of total health care spending in 1998 (Liberman and Rolle, ...