The Challenge of Cheating in the Health Service. Consumer Vigilance: The Impact of Health Care Fraud on Patients
With the development of health insurance in Indonesia, which has reached 42%
of the total population, it has health insurance to ensure vigilance against possible fraud and abuse cases. The increase in health care costs that
occur only due to the occurrence of fraud must be avoided. Therefore,
participation as a consumer is needed to prevent and reduce the possibility of
fraud. This vigilance is not unfounded looking at data from the National
Anti-Fraud Health Care Association (NHCAA), which estimates that financial
losses from healthcare fraud run into the tens of billions of dollars each
year. We should not be lulled into the thought that cheating in the health
service has no victims when it is known that affair has a very bad influence.
When looking at
the many frauds that occur in the health service, it turns out that most health
care fraud is done by a small percentage of dishonest people from health care
providers. So that it can finally tarnish the reputation of the most trusted
and respected members. With that opportunity, a small percentage of dishonest
people can develop into more and more experts to access various fraud forms. So that all potential treatment medical conditions become the basis
of false claims and spread fraudulent bills in many insurance companies that
are claimed simultaneously also need to be wary:
As patients need to be aware of some acts of fraud in the health service committed by dishonest providers, including:
- Billing for services that are never
provided uses genuine patient information, sometimes obtained through
identity theft, to make entire claims or false claims at a cost to
services that were never done.
- Billing for services is more
expensive than the procedures actually provided or performed, commonly
known as "upcoding"—that is, fake billing for treatment of
higher-than-actual prices.
- Performing unnecessary medical
services only those aimed at generating insurance payments is seen often.
- The error of treatment, which
medically aims to get as many insurance payments as possible.
- Falsifying a patient's diagnosis to
justify tests, surgeries or other medically unnecessary procedures, such
as cosmetic surgery cases claimed to be cases of accidents.
- Unbundling - billing each step of the procedure as if it were a separate procedure. Example: Chest and abdominal ultrasound is billed differently, at once,Appendectomy and hysterectomy surgery is self-billed, and so on.
- Billing patients is more than the amount co-pays for
services that are prepaid or paid in full by the rewards program under the
terms of the managed care contract.
- Accepting bribes to refer patients,
even though the referral is not needed by the patient
As a patient, there are several things to watch out for to minimize the risk of health care fraud.
Diagnosis, treatment, and medical records are false.
Several patient names were claimed by the parties for the month concerned; only some actually visited, the rest only used identity cards without the patient actually being treated. Some patient names are submitted with visits of more than 1x, which is actually the patient-only treatment x. This means that when a patient needs insurance benefits, the treatment ratio is likely only a little even exhausted because it has been abused.Medical Identity Theft
As consumers must be aware of identity theft because it turns out that there are 250,000 to 500,000 people have been victims of this crime. When a person's name or other identifying information is used without knowledge or consent to obtain medical services or file a false insurance claim for a patient's payment, it constitutes medical identity theft. Medical identity theft often leads to incorrect information being added to a person's medical records or even making medical records entirely fictitious on behalf of the victim. Victims of medical identity theft may be able to receive the wrong medical treatment. The effects of these crimes can interfere with the medical and financial status of the victim for years to come.Physical risk for the patient
Needs to be wary because this problem is a case where the patient has undergone an unnecessary or dangerous medical procedure just because of the greed of the health care provider. In June 2002, for example, a cardiologist in Chicago was sentenced to 12.5 years in federal prison and ordered to pay $16.5 million in fines and damages after pleading guilty to performing 750 unnecessary medical cardiac catheterizations, along with unnecessary angioplasty and other tests over 10 years. Three different doctors and hospital administrators also claimed guilty and received prison sentences for engaging in the cheating scheme, which resulted in the deaths of at least two patients.Health care fraud and criminal group organizations.
Health care fraud is not just perpetrated by dishonest health care providers. In South Florida, government programs and private insurers have lost hundreds of millions of dollars in recent years. Those in Central and South America make claims from non-existent clinics, use insurance, and actual patient providers. Many states have also responded vigorously since the early 1990s, not only by strengthening their insurance fraud laws and penalties but also by requiring health insurance to meet certain standards for fraud detection. NHCAA pursues its mission by enhancing private-public cooperation against health care fraud at both the case and policy levels, facilitating the sharing of investigative information between health insurers and law enforcement agencies, and providing information on health care fraud to all interested parties.
There are several things you can do to avoid fraud in the health service:
- Protect your health insurance ID card
like a credit card. If it is in the wrong hands, then the health insurance
card will be stolen. Don't give numbers to salespeople, lawyers, or over
the Internet. Be careful when disclosing information about your insurance
and if you lose your insurance ID card, report it to your insurance
company immediately.
- Report any form of fraud. Contact
your insurance company right away if you suspect you may be a victim of
health insurance fraud. Many insurance companies now offer the opportunity
to report suspected fraud online through their websites.
- We are asked to be as informative as
possible to tell about the health services we receive, keep a good record
of medical care, and pay attention to all medical bills we receive.
- It is necessary to read the policies and benefit statements. Read your policy, The Benefits Report Explanation (EOB), and any documents you receive from your insurance company. Make sure you actually receive the insurance treatment you charge and question the cost if anything is suspicious. Is the service date documented on the correct form? Is the service identified and billed for the service that was actually performed?
- Beware of "free" offers.
Free offers of health services, tests, or treatments often use fraudulent
schemes designed to charge you and your insurance company. Fraud in the
health service is a serious crime that affects everyone and should concern
government officials and taxpayers, insurance and premium-payers, health
care providers and patients, and hope that none of us ignores the potential
fraud.
