Financial Issues For The Health Care System Of The United...

Background Pozgar (2012) defines healthcare fraud as an unlawful act, which purpose is for personal gain through deception. It consists of a vast number of illegal acts and irregularities resulting from intentional deceptions. It is no surprise that healthcare fraud is difficult to combat and causes extensive financial issues for the health care system of the United States. This brings us to define what fraud is and how it relates to healthcare. Fraud generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody†¦show more content†¦Ã¢â‚¬ ¢ Providing or conducting procedures that are not ultimately required or needed in order to obtain insurance payments. †¢ Illegally representing treatments or procedures that are not covered in insurance plans as medically necessary treatments that are covered by the insurance. This type of fraud is done to receive payments from patients insurances. †¢ Illegally changing or falsifying a patient’s diagnosis in order to justify any test, surgeries or other procedures that are not required or deemed as a medical necessity. †¢ Taking a procedure and breaking it down into steps and then billing each of these steps as if it were an entirely separate procedure. This is known as unbundling. †¢ Ignoring the terms of a managed care contract and billing a patient for more than what is required for the co-pay amount for services that was already paid for by the benefit plan of the patient. †¢ Illegally accepting kickbacks (receiving a form of payment) or paying for patient referrals. †¢ Providers who may waive a patient’s co-pay or deductible for and health care service provided and over-billing the insurance carrier or benefit plan of that patient. This can only be done under special circumstances, for example Medicare will allow the payments of co-pays or deductibles if the patient is under considerable financial hardship. Healthcare fraud is an issue that needs to be addressed. There are several different methods and solutions to reduce the occurrence of fraud in healthcare