Even if you have not heard much about it lately, know this: health care fraud is alive and well in the United States. Here is a roundup of recent stats, law enforcement initiatives, common fraud schemes, and how you can help prevent these crimes.
Just the facts
During fiscal year (FY) 2018, the Health Care Fraud and Abuse Control Program (a government initiative that coordinates federal, state, and local law enforcement) won or negotiated more than $2.3 billion in health care fraud judgments and settlements. During the same period, the Department of Justice (DOJ) opened 1,139 new criminal health care fraud investigations. In addition, the DOJ filed charges in 572 criminal cases.
What does this mean for you? The National Health Care Anti-Fraud Association estimates that health care fraud costs the nation at least $68 billion annually.
Many players, many games
Health care fraud can be perpetrated in a variety of ways by many different players. For example, insurance companies may defraud government programs such as Medicare and Medicaid by submitting false documentation, mishandling claims, charging excessive rates, or failing to pass along discounts.
Fraud by insured employees is another problem. Employee-initiated schemes include submitting fraudulent claims — often in collaboration with shady medical providers.
Dishonest providers, including doctors, nurses, chiropractors, and pharmacists, are responsible for a large volume of health care fraud. They may bill for unnecessary or harmful medical procedures, bill for procedures never performed, ‘upcode’ inexpensive procedures to expensive ones, or bill for brand names and dispense generics. Corrupt practitioners may recruit healthy individuals and bill their insurance companies for costly medical services that are never provided.
What you can do
Fraud thrives in high volume environments. So, the more health care transactions your business or organization processes, the greater the potential for fraud to slip through undetected and the more vigilant you must be.
You can help combat these schemes by strictly complying with audit obligations. For instance, randomly sample products and services invoiced and compare them with what was actually delivered to the patients. Looking for discrepancies can net you stolen goods and even large-scale thefts. It also sends a message to potential perpetrators that you are watching.
Role of internal controls
In addition to contractual audits, internal controls play an important role in preventing and uncovering health care fraud. Contact us if your organization needs help building a robust internal control system.