Healthcare fraud in America is a multi-billion dollar a year problem. Fraud affects all of us by producing higher healthcare premiums and shared costs. Until we, as a country, contain this problem, costs will continue to soar for everyone. Why doesn’t the Governor, as part of his health care proposal, put extra resources toward the investigation and prosecution of the perpetrators of health care fraud? We have very few resources dedicated to investigating and solving these crimes, prosecution is lengthy and the penalties are not as severe as they should be. With the passing and enforcement of the Transaction Simplification portion of HIPAA, there will be new ways to perpetuate fraud. Every time a electronic perimeter is put in place, there will be someone that will find a way to get around it. This will be a constant battle.
Until politicians step up to the plate and take a stand employers, small and large, can institute programs to help curtail rising healthcare costs. Here are some points to consider:
- Inform employees of the cost of perpetuating healthcare fraud and that the costs are eventually shifted back to employers and employees by way of higher premiums and costs.
- Share the actual cost of healthcare and other benefits with your employees. Dissuade the thoughts that ‘Insurance will pay for it" by explaining how unnecessary utilization of benefits will increase costs.
- Inform employees when an advertisement is received indicating that there are ‘no out-of-pocket’ costs, there may be fraud involved. Be aware of the costs that are actually incurred for individual healthcare. Was that x-ray or lab test being charged really performed? Did you receive all the medications for which you are being charged? Did you really see that provider on the dates indicated?
- Encourage employees to report billing discrepancies promptly.
- Follow through with all the pre-authorizations required for hospitalization, surgery and high cost procedures.
- Encourage case management for employees and dependents that might be incurring catastrophic medical expenses.
- Advise employees to choose their healthcare providers carefully.
- Institute wellness programs
- Report suspected healthcare fraud to the carrier involved and the proper authorities and follow through until resolved.
- Be diligent in reviewing your company’s healthcare costs on a regular basis.
To learn more about healthcare fraud and what is being done about it you can visit:
Consumer Information: http://www.nhcaa.org/about_health_care_fraud/Consumer_Information/
Enforcement Activities: http://www.usdoj.gov/dag/pubdoc/hcfacreport2005.pdf
#1 by Darrell Wells on January 10th, 2007
The principle reason that the Governator’s plan does not address fraud is that fraud is so endemic to the health care system that the revenues of almost ALL physicians and hospitals and chiropractors and medical device makers and ancillary services such as Rx and imaging etc. would be SIGNIFICANTLY impacted. FRAUD accounts not for just a few percentage points but one of the bigget slices of the pie. Almost ALL providers engage in some fraud and quite a few get a MAJORITY of the revenue from fraud.