Motivators of Fraud in Health Care
Grantham University
Motivators of Fraud in Health Care:
Paul L. Ewing
G00019834
White-Collar Crime
Mrs. Sandra J. Putnam
December 25, 2012
What are the motivators of Health Care fraud? At first thought, I suspect it was for the love of money but then I felt like it has to be more to it than that. Why would people risk it all to defraud insurance companies and even the government? After a while, it’s clearly not about the money because the longer a company goes without being caught, they won’t be hurting for financial wealth so why continue? How do you know when you are being charged for test and check that you don’t need? During this essay, I will answer these questions as well as describe what acts as motivators for these health Care frauds.
According to the text, the health care industry is the (single largest single industry) in the United States economy. The structure of today’s health system, it leaves huge opportunities for fraud to take place. Back in the early 1980’s; doctors would provide medical care to patients and then later file a claim with the issuance company of the patient or send a bill in the mail for the patient. Prior to a doctor submitting his or her bill, it would be reviewed by a medical coder who was able to determine the legitimacy of treatment that was required. With the presence of modern technology, doctors file their claims but now they are reviewed by computers which open the door for more opportunities to defraud the insurance companies. In these situation, I feel the fraud in this case is motivated by the fact that those insurance companies don’t find it very important to review claims and therefore are only getting always with what insurers are allow to. Those committing healthcare fraud include organized criminal groups, individuals, and health care providers. The individuals committing healthcare fraud see the crime as low risk and high reward since many perpetrators are never caught. If they are
Motivators of Fraud in Health Care:
Paul L. Ewing
G00019834
White-Collar Crime
Mrs. Sandra J. Putnam
December 25, 2012
What are the motivators of Health Care fraud? At first thought, I suspect it was for the love of money but then I felt like it has to be more to it than that. Why would people risk it all to defraud insurance companies and even the government? After a while, it’s clearly not about the money because the longer a company goes without being caught, they won’t be hurting for financial wealth so why continue? How do you know when you are being charged for test and check that you don’t need? During this essay, I will answer these questions as well as describe what acts as motivators for these health Care frauds.
According to the text, the health care industry is the (single largest single industry) in the United States economy. The structure of today’s health system, it leaves huge opportunities for fraud to take place. Back in the early 1980’s; doctors would provide medical care to patients and then later file a claim with the issuance company of the patient or send a bill in the mail for the patient. Prior to a doctor submitting his or her bill, it would be reviewed by a medical coder who was able to determine the legitimacy of treatment that was required. With the presence of modern technology, doctors file their claims but now they are reviewed by computers which open the door for more opportunities to defraud the insurance companies. In these situation, I feel the fraud in this case is motivated by the fact that those insurance companies don’t find it very important to review claims and therefore are only getting always with what insurers are allow to. Those committing healthcare fraud include organized criminal groups, individuals, and health care providers. The individuals committing healthcare fraud see the crime as low risk and high reward since many perpetrators are never caught. If they are
References: Benson, M. L. & Simpson, S. S. (2010). White-Collar Crime: An Opportunity Perspective, research, 9-12. https://www.nampi.org/members/2010presentations/KeynoteAddress.pdf http://mjpetro.typepad.com/7th_circuit_alert/2011/07/42-usc-1320a-7b-medicare-fraud-primary-motivation-doctrine-rejected.html