Essay On Healthcare Fraud

Healthcare fraud is a major issue in our Healthcare system. It affects our overall economy and well-being of our citizens. There are many different types of healthcare frauds such as insurance fraud, drug fraud and billing fraud. Insurance fraud occurs when the insurance provider is given false insurance claims with the intent to defraud. As a result of frequent false insurance claims, the inspection procedure uses the best available experts and verification process to check the false claims. But, due to not having enough man power and heavy workload mistakes still happen and which leads to settlement of claims and waste of social resources. Drug fraud usually occurs when legal drugs or illegal drugs are used for personal profit or their prices are altered. Most of the time pharmacy workers are involved in frauds. They short count the pills or fill prescription without a refill. Pharmacy workers also have easy access to prescribed drugs which makes it easier for them to steal it. Other types of drug frauds include visiting different doctor offices to obtain narcotics, getting prescriptions on a stolen physician’s pad, impersonating medical staff to get drugs and changing the amount on doctor’s prescription.
Billing frauds include billed for services that are not provided, billing for a non-covered service as a covered service, misrepresenting location date or provider of the service or overutilization of services.
Billing for services not provided is one of the most common frauds because it is pretty straight forward. “upcoding” , Unbundeling” and “phantom biling” are also some common terms in billing frauds. “upcoding” occurs when patients are charged for services that are higher than services actually provided. For example a patient make get charged for broken ankle even though he just has a sprain ankle. Biling for services not provides is called “phantom biling”. “unbundeling refers to services billed separately to charge more
money. A prominent cardiologist based in Central Florida named Asad Qamar and his practice Institute of cardiovascular Excellence( ICE) were sued for two lawsuits for systematic medical fraud. His frauds included performing unnecessary procedures, improperly billed Medicare, Medicaid and Tricare and paid kickbacks to patients. The lawsuits were filled in 2011 and 2014 by two whistleblowers but kept secret because The U.S. Department of Justice was investigating the case. Holly Taylor a native of Sarasota who is a medical billing consultant was one of the whistleblowers while the other whistleblower was a john Doe. According to the John Doe complaints Qamar performed unnecessary tests on patients to increase medial payments. Most of time patient’s symptoms were falsified to support unnecessary tests. Some of these tests included nuclear imaging, Holter monitoring for the heart and ultrasound for blood flow in the leg. John Doe also alleged that Qamar performed unnecessary Catheterization of heart. On the other hand Holy Taylor alleged that US and state of Florida were defrauded of “tens of millions of dollars”. Dr. Qamr was accused for “Upcoding” which is billing for a higher service than one actually provided, procedures not performed all the way, and waving 20 percent co-payments which Medicare requires patients to pay. She also alleged that Dr. Qamar performed catheterization without looking at patient’s lab reports or patient’s history. As a result of these lawsuits The US Justice Department announced that Qamar was excluded for 3 years from any federal healthcare program. Dr. Qamar and his practice Institute of Cardiovascular Excellence (ICE) were also asked to pay $2 million plus any claim to $5.3 million in suspended Medicare funds. Dr. Qamar agreed to this three year exclusion from performing in any healthcare program followed by three year integrity agreement with the department of Health and human services.