Combatting And Preventing Healthcare Fraud


An unbelievable sixty billion dollars are estimated to be lost due to fraud in healthcare over just one year! When there is an intention to deceive to obtain unlawful gains, and when you are depriving someone of their legal rights, it means you are committing fraud. We review most common ways healthcare fraud is committed and how to prevent healthcare fraud.

There are many examples and models of healthcare fraud:

  • When you are misrepresenting the kind of services, you have provided.
  • When you add to the bill items and services that were not rendered at all.
  • The bill includes payments for services not mentioned clearly in the documents.
  • Asking for a higher rate of payment or reimbursements for services rendered which should be billed at a lower rate (up-coding).
  • Increasing the amount of the bill for medically unnecessary services.
  • In cases where the individual who is rendering the services is misrepresented.
  • Billing for payments of procedures conducted integral to the procedures performed on a particular day or date (unbundling).

Moreover, another highly common practice is the abuse of healthcare. Abuse can be explained by saying that it is a practice that goes against the consistent or accepted medical practices and falls behind and does not meet the recognized healthcare standards.

People involved in the practice of healthcare fraud and abuse are committing acts of crime and are liable to be punished. The government and private organizations have taken effective measures to try to combat and prevent healthcare fraud.

They are playing a critical role in this fight and have been quite successful in recovering millions of dollars lost in cases of healthcare fraud. To prevent healthcare fraud, there are many ways in which you as an individual can help.

Preventing Healthcare Fraud:

Check and make sure that your bills are exactly accurate for the services that have been provided to you.

  • Before rendering any kind of service, you must validate all the members’ identity cards.
  • Always make it a point to report stolen or lost prescription pads.
  • If you are suspicious of or doubt a fraud has occurred, report immediately to the concerned authorities.
  • Fill and submit the appropriate forms for referrals and treatments.
  • Do not go for unnecessary medical treatments or drug prescriptions.

You can learn more through research with the following programs that help prevent healthcare fraud and abuse.

The Healthcare Fraud and Abuse Control Program

This program was started in 1997 and has helped protect consumers from healthcare fraud and abuse quite successfully. Other departments of Medicare and Medicaid have enlarged their ability to combat these frauds by using new and powerful anti-fraud tools.

The Medicare Fraud Strike Force

This is a team of investigators, analysts, and prosecutors whose aim is to look for possible fraud schemes, and together with the Healthcare Fraud Prevention and Enforcement Action Team, they have conducted nationwide operations and have charged doctors, nurses, and other medical professionals for taking part in healthcare fraud schemes.

Modern Technology In Use

For the detection of healthcare frauds, state-of-the-art fraud detection technology is being put into use. New methods and tools are being developed to analyze and evaluate data of consumers, patients, and practitioners to identify potential fraud trends and patterns.

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