Planning to fail is failing to plan an investigation
In every society, health care is vitally important. Improving the quality of health care without increasing the cost in an important challenge facing every aspect of the health care system. While many various steps can and should be taken to achieve this goal, one area that is often overlooked is identifying and preventing health care fraud.
Preventing health care fraud is important because it robs the health care system of money, increasing the costs for everyone involved. Criminals create various schemes to fraudulently acquire money for goods or services not needed or performed. When this occurs, everyone loses, and the entire health care system suffers. Because of this, preventing and catching those criminals is a vitally important to the flourishing of health care.
Unfortunately, health care fraud can be extremely difficult to prevent. This means that individuals and businesses involved in health care must be intentional in preparing and planning to prevent from becoming victims of fraud. Because of its nature, fraud is generally not obvious, and can come in many different forms, and is therefore hard to detect. Unless serious preparations are made, individuals and businesses run the risk of being victimized by health care fraud.
In order to be properly prepared, a knowledge of how to investigate health care fraud is essential. Fraud examination and investigation is the process for resolving fraud allegations, which involves obtaining evidence, creating reports, and testifying to these findings. In this arena, knowledge and preparedness can be the difference between being a victim of fraud or not.
The first, and perhaps most important way to prevent fraud and to know when to investigate is to know the common warning signs and strategies. Knowing the common types of fraud allows for quicker recognition of when that fraud may be occurring. Some common examples of fraud include providers billing for services not provided, billing insurance companies for equipment that is not medically necessary, administering overly expensive tests and equipment, or even policy-holders letting others use their healthcare cards. Check with local and national government websites for further common fraud tactics.
Once the various approaches criminals use for fraud are known, the next step is to watch for anomalies; these will serve as warning signs. For example, one might watch for doctors who bill for treating an abnormally high number of patients each day, for companies selling a significant number of medical equipment based mainly on references from one clinic or doctor, or for doctors prescribing certain medications at a much higher rate than usual.
One example of this is in the case of a doctor in the United States. In 2013, Dr. Darrell Hall was convicted of conspiracy to distribute a controlled substance and health care fraud. He fraudulently billed Medicare for nearly three years, and prescribed and distributed the medication oxycodone without medical reason. While Dr. Hall committed fraud for three years before being caught, eventually the anomalies in his billing and prescribing caught up to him, allowing the proper authorities to convict him for his crimes.
Once these anomalies are detected, they can serve as signals that fraud is taking place. Once fraud is suspected, a careful collection of relevant information and evidence is crucial. Without this step, it is extremely difficult to convict criminals of fraudulent activities. The evidence that is needed varies depending on the case, but in general evaluation of aspects of billing, documentation, and statements by those involved are a part of this process.
The final step in this process is preparing this evidence into a written statement or report, detailing the various aspects of the fraud and the evidence. This compilation of data can then be used as part of a prosecution or suit against the criminals involved.
Through preparedness and careful and thoughtful planning, health care fraud can be deterred and prevented. However, it takes intentional effort on the part of all involved. Without this effort, fraud will continue to increase and damage healthcare. But if all players in the health care system work diligently against fraud, steps can be taken to limit fraud and convict criminals.
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