What Reform We Can Bring to Curb Health Care Fraud!

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What have we created in health care? A tower of Babel! While the market attempts to correct itself and U.S legislative and executive branch politicians most likely pursue their seventh attempt since 1927 and President Obama made his way to the presidency by claiming that he will bring a revolution to the health care for the people of America, but now it’s more than 3 years and we haven’t seen praiseworthy impact of his reforms.

A part from a political overview, health care is a very sensitive issue in all parts of the world. Not only the third world underdeveloped countries, the countries like United States of America and European Union has always been seen in crisis over health care across the past decades, although the advancement in science, research and technology has brought wonders but still the health care frauds and health care crimes are increasing in huge numbers.

Actually we don’t really need a reform in the health care industry but we need an approach to find out the places where a highly developed country can also lack in services of health care. Picking out the health care fraud right from its root cause can curb the problem in a huge and deciding manner.

Health care fraud is a crime which is not roaming around only to the health care provider level but there are other major contributors like patients, health care tax payers, employers, insurance plan sponsors, and health care vendors also.

Health care fraud steals the very essence of human life. Stories include false claims by perpetrators, who perform needless procedures that disable or kill, fake insurance broker or inappropriate payer denials that leave a patient disabled or with untimely death, and fake drugs etc. The list of examples is more shocking and demoralizing and generates a sense of hopelessness.

10 Things Which Indicate a Health Care Fraud:

• Medical incidents or medical practices that are not consistent with the standard of care (substandard provision of health care).

• Unnecessary cost to a health care program caused either directly or indirectly.

• Improper payment or payment for services that fail to meet professional standards.

• Medically unnecessary services

• Substandard quality of care (e.g., in nursing homes)

• Elaborated Schemes and cover-up strategies and failure to meet insurance coverage requirements.

• False statement of services rendered or goods provided.

• Obtaining insurance information and filing claims for fictitious medical treatment.

• Unreasonable rates and misrepresentation of value and services regarding health care.

• Consumer health care fraud. One example is forging family names to provide coverage to friends with the intention of dividing up the reimbursement.

Recommendations for Prevention of a Health Care Fraud:

Monitoring System:

Continuous monitoring of;

1. Patient activity.

2. Provider activity.

3. Payer activity.

4. Employer activity.

5. Vendor activity.

6. Organized crime activity.

Prevention System:

Continuous development in;

1. Fraud prevention goals.

2. Fraud Deterrence strategies.

3. Fraud detection methods.

4. Fraud investigation criteria.

5. Fraud loss and costs recovery system.

6. Anti fraud controls, effectiveness and remediation measures.

7. Anti-fraud Education and Training.

Muhammad Saad Khan is an Executive at Q2 Group. Q2 is specialized in medical credentialing, primary source verification, and medical license verification according to the standards of joint commission international. For more about health care fraud cases, please visit (http://medicallicenseverification.com).

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