Enforcment Against Healthcare Waste and Fraud Research Paper

  • Length: 10 pages
  • Sources: 5
  • Subject: Health
  • Type: Research Paper
  • Paper: #93247256

Excerpt from Research Paper :

Healthcare Fraud

Identity theft and fraud of many types and forms are obviously a major inconvenience and hindrance to anyone that falls prey to a person that engages that crime. There are many variants and forms of fraud and identity theft out there. One of the more insidious and nasty examples of those crimes would be that which relates to healthcare. Indeed, to have people's wallet, healthcare and the taxpayer dollar on top of that all potentially compromised in one fail swoop is a very ominous and nefarious endeavor. Even so, it happens all of the time and to all sorts of people. Regardless of the particular situation or scenario, any instances of fraud or abuse when it comes to healthcare insurance, healthcare providers and the services dispensed from all of the above are never a good thing. While healthcare is deemed to be a right to be extended without limitations to all Americans, the presence of abuse and fraud only complicates matters and prevents this from happening in some cases.


Report Structure

In a nutshell, this report will focus on the gravity and significance of healthcare fraud and abuse as an issue. This problem will be explored and summarized from a political, economic, social and ethical perspective. The specific populations involved run the gamut from individuals to families to communities, cities and to the healthcare system itself. There will be a reflection on what all is going on and what can be said about it and there will also be a listing of gaps that apparently exist when it comes to the literature. A conclusion and recap of the findings will be part of the body of work in this report as well.


Before getting to the particular findings and analysis related to this problem, it would be wise to recap the situation and the challenge at a high level. The abuse and misuse of the federal and ancillary healthcare systems in the United States has reached a level that has made it a top priority when it comes being addressed by the federal government. While general inefficiencies and the veritable hodgepodge of systems and frameworks that make up the healthcare system are bad enough, there are those that unapologetically and/or illegally breach and exploit these inefficiencies and problems. The government investigations and inquiries that have resulted from both of the above has led to a lot of disdain and dissatisfaction on the part of providers and such as being investigated on its own, even if there is no merit to the idea that a provider is part of the abuse, can be stigmatizing and can absolutely kill productivity and a firm's reputation. Healthcare administrators in particular are often behind the proverbial eight ball in that they have to seek ways to reduce the chance that his or her employer will become the target of a fraud investigation due to red flags being tripped or an accusation being made by a person or agency that the administrator's employer has contact or interaction with. Given that, administrators have to put themselves out there and assert that the documentation and coding done by the firm is complete, that it is accurate and that it is done in an ethical and legal way. The documentation, digital or paper, must support what did or did not happen for each patient that comes through the front door. Indeed, the claims reimbursement process hinges on honesty and completeness and when it comes to a healthcare practice, the administrator and his/her subordinates are responsible for making sure things happen properly and correctly (Budetti, 2015).

In addition to the above, there is an absolute duality when it comes to the healthcare paradigm, especially when it comes to for-profit offices and collectives. Indeed, there is the patient care side of things and the corporate/administration side of things. Both sides to the practice have their own list of rules and bylaws that must be followed to the letter. It is often perceived and not actual, but many hold that there is a conflicting mindset and duty when it comes to the two sides of a practice and what goes into its operations. Indeed, a for-profit business is all about making money but medical care is about care quality, attaining the best outcome and so forth irrespective of the money that has to be spent to get to that end. To be sure, this does not mean that waste and over-diagnosing should be done. At the same time, treating patients like regular customers and not people with valid concerns about their life and livelihood is less than wise. Making medical decisions about things that are not aesthetic and voluntary in nature based on money is also an ethical landmine because the idea is that healthcare should be about doing what is best for the patient rather than the money that has to be spent when it comes to the same (Budetti, 2015).

Given this paradigm, it is exceedingly prescient and wise for there to be corporate compliance programs at clinical practices that weigh and balance these sometimes opposing ideals and concerns in a way that is efficient, ethical and legal all at the same time. Effective strategies can and should be drawn up that ensure that all relevant regulations and ethical standards are complied with while also minimizing the chance of fraud or risk when it comes to healthcare administration. For example, there should be a coding compliance program and it should serve as a linchpin for any wider corporate program for medical practice. Further, there should be a risk assessment so as to identify risks, what impact they could have and what should be done when those risks are manifested and identified. It takes administrators that are proactive and creative so as to allow for the convening and execution of a multi-disciplinary team of professionals, both medical and administrative, that get things done and do them in the right way. This team of professionals can and should make it a point to address the compliance plan for the firm and they should cooperate with each other when it comes to perfecting the policies and procedures that the firm will use so as to stay within the ethical and legal boundaries that exist (Budetti, 2015).

Economic Issues

When it comes to the economic facets of what fraud and abuse end up causing, these are not hard to figure out or consider. Indeed, economic issues are all about how much services cost, whether patients have the ability to pay for services, where those payments come from and so forth. When there is rampant fraud and abuse, there are a number of effects that have vast economic implications and consequences. Just as one example, the economic expenses and results from fraud and abuse find a way back to impacting the innocent practices and clients in one way or another. For example, if a person files a specious malpractice suit or even just incurs legal costs for a provider to begin with, verdict or not, this causes malpractice insurance to be more expensive and this leads to higher overhead for a provider. Beyond that, it is often cheaper and less aggravating for a doctor to just settle as having a prolonged legal battle and/or a questionable verdict that could total in the millions is deemed to be not worth the problems that are dealt with. When it comes to claims and such that are clearly fraudulent or when it comes to people that use services in a name other than their own, this would generally lead to unpaid claims. This would impact the economics of someone if their identity were stolen and this too would drive up the overhead and unrecoverable costs that a medical firm would endure. While there are limitations and roadblocks put in place to prevent patients from paying too much, this can generally be gotten around in the form of what is charged to non-insured patients, whether an office will financially penalize a person who misses an appointment (and to what degree) and so forth. There are enough economic problems due to the overhead and aggregate costs going higher and higher. People are skipping doctor appointments and putting off treatment when they absolutely should not be doing so and this is a huge part of why minorities are the hardest hit when it comes to these things given that they tend to be among the poor and disadvantaged. Regardless, the economic impacts of fraud and abuse impact everyone. In some limited cases, the fraud and abuse comes from the patient himself/herself. Indeed, a common cold should not generally require a doctor's visit and it certainly should not involve a trip to the emergency room. That is an issue but people that are outright lying to gain money or free treatment are obviously the bigger problems. Healthcare should be there for those that reasonably need it...no more and certainly no less (Golinkin, 2013).

Political Issues

As for the…

Sources Used in Document:


Badano, G. (2016). Still Special, Despite Everything: A Liberal Defense of the Value of Healthcare in the Face of the Social Determinants of Health. Social Theory &

Practice, 42(1), 183.

Budetti, P. P. (2015). New strategy, technology emerging in ongoing fight against healthcare

fraud. Modern Healthcare, 45(29), 25.

Cite This Research Paper:

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