Tag: Reform

Healthcare Reform – The ‘Public’ in Public Option

Healthcare Reform – The ‘Public’ in Public Option

Mention death and many people recoil in discomfort. Although death is very much a stage in the circle of life, many people see it as an end and live their entire lives in search of a miracle elixir that will keep them going long after…

Coventry Health Plans – Federal Healthcare Reform Compliance

Coventry Health Plans – Federal Healthcare Reform Compliance

Coventry health plans, like all plans offered in the United States, are required to meet the new federal guidelines for healthcare reform. These reforms change benefits, exclusions, and limitations for all healthcare plans offered in the U.S. with few exceptions. Such reforms include coverage for…

What Reform We Can Bring to Curb Health Care Fraud!

What Reform We Can Bring to Curb Health Care Fraud!

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 healthcare 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, healthcare 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 healthcare across the past decades, although the advancement in science, research and technology has brought wonders but still the health care fraud and healthcare crimes are increasing in huge numbers.

Actually we don’t really need a reform in the healthcare industry but we need an approach to find out the places where a highly developed country can also lack in services of healthcare. 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 healthcare provider level but there are other major contributors like patients, tax payers, employers, insurance plan sponsors, and healthcare 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 healthcare).
  • Unnecessary cost to a healthcare 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 healthcare.
  • 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. Antifraud Education and Training.

Source by Muhammad Saad Khan