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Combating Healthcare Fraud and Abuse

Fraud as well as abuse, prevalent in both the community and private wellbeing segments, is reported in about 3 percent to 10 percent of Medicaid expenditurecountrywide. Among 28 central programs surveyed by the U.S. General Accountability Office each year, Medicaid had the highest number of improper payments.Health care fraud and abuse control programs that are planned to check, recognize, and act againstunauthorized billings by health care professionals, patients as well as insurers. Health care fraud refers to deliberate deceptiona falsification or failure to reveal pertinent information. A fake claim involves an intended false depiction that causes the government to pay more than is permissible. Abuse involves inferior, inattentive or medically needless practices that add to the charges of health care. As per the report titled “Healthcare Fraud Detection Market“; published by UnivDatos Market Insights. Between 2005-2019, the total number of individuals affected by healthcare data breaches totaled 249.1 million. Among these 157.4 million individuals were affected in the last five years alone globally. In the year 2018, the number of data breaches reported was 2,216 from 65 countries. Out of these, the healthcare industry faced 536 breaches, which implies that the industry is facing the highest number of breaches, compared to other industrial sectors.

Fraud and Investment Retrieval in the Healthcare Sector

One of the most important government initiatives is the Health Care Fraud and Abuse Control Program (HCFAC), established in 1996. HCFAC is a joint Department of Justice Health and Human services effort to coordinate federal, state, and local law enforcement activities against health care fraud and abuse. On May 2009, an HHS/DOJ information-sharing and collaboration initiative, the Health Care Fraud Prevention and Enforcement Action Team advanced HCFAC’s efforts and contributed to the success of enforcement activities. The figure below shows the HCFAC data for the budget and recoveries in the recent years.

Laws Against Individuals Involved in Fraud and Abuse

The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), and the Physician Self-Referral Law (Stark law). Government organizations, together with the Department of Justice, the Department of Health and Human Services Office of Inspector General (OIG), and the Centers for Medicare and Medicaid Services (CMS), are to look after the implementation and enforceability these laws. Violation of these laws could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of medical license. These laws are summarized below.

  • False Claims Act:The civil FCA aims to protect the administration from being overcharged or sold poor goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that one knows or should know are false or fraudulent. Filing bogus claims may lead to fines of up to three times the programs’ loss in addition toUS$11,000 per claim filed. Under the civil FCA, every instance of an article or a service to be paid to Medicare or Medicaid counts as a claim, so fines can add up rapidly.
  • Anti-KickbackStatute:The AKS is a criminal law that restricts the deliberate and willful compensation of “remuneration” to persuade or incentive patient referrals or the creation of business involving any item or service to be paid by the Federal health care programs (e.g., supplies, drugs, or health care services for Medicare patients). Criminal penalties and organizational sanctions for violating the AKS include jail terms, fines, and barring from involvement in the Federal health care programs. Under the CMPL, healthcare professionals who allow or accept kickbacks are also charged with penalties of up to $50,000 per kickback plus three times the sum of the remuneration.
  • Physician Self-Referral Law:The Physician Self-Referral Law, generally known as the Stark law, restricts healthcare professionals from referring patients to accept “designated health services” to be paid by Medicare or Medicaid from entities with which the physician or adirect family member has a pecuniary relationship. Pecuniaryassociationscompriseof both ownership benefit and compensation planning. The Stark law is a strict liability statute, which means proof of specific intent to violate the law is not required. Penalties for healthcare professionals who breach the Stark law consist of fines as well as prohibiting from involvement in the Federal health care programs.

Improper Payments Analysis

Health-care expenses in the United States surpass $2 trillion a year. Determined by the market size, health care has become asignificant and rapid growing relevance domain for data analytics. McKinsey’s influential report on big data analytics lists health care as the top most promising application domain. One majordifficulty of health care is the failure of health-care expenses to fraud, waste, and abuse (FWA). The table below lists the improper payments for the recent years.

YearImproper payments % (Healthcare related)Improper payments % (Non-healthcare Related)

Outlook for Upcoming Years

Toeffectively address issues of fraud and abuse, accountability, ownership, and consequences for actions must cross the continuum at the individual physician or healthcare professional, healthcare provider, managerial, and federal levels. Providers and the consumers must be devoted to providing suitable documentation to focus on abuse issues and obtain anhonorable and ethical stand against fraud in the healthcare background. This may mean taking benefit of the FCA whistleblower laws to recognize fraudulent claims to the suitable federal authorities. Healthcare providers and organizations ought toinvest in contribution to education and training programs, utilizing data mining and modeling software, and creating coding and fraud and abuse committees. Also, the federal government ought to be attentive in prosecuting healthcare organizations, providers, and persons who commit fraud and abuse in an ordered and organized manner.

Author: Ankush Sharma

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