The United States’ health care system is hemorrhaging billions of dollars. On average, a staggering $700 billion in annual waste occurs year after year, with “fraud and abuse” representing the extreme end of the waste continuum. The National Healthcare Anti-Fraud Association, an organization of about 100 private insurers and public agencies, estimates that some $60 billion, or about 3 percent of total annual health care spending, is lost to fraud every year and that figure is actually considered conservative.
Health care fraud is more prevalent and the costs more damaging than you probably imagine. While fraud in the system is actually perpetrated by a very small percentage of people, it ultimately affects every patient, doctor and hospital in the country and results in damaged reputations for hospitals and medical professionals, and distrust between insurance companies, doctors and patients.
If suspected of health care fraud, hospitals, doctors, rehabilitation specialists and other providers often face simultaneous civil and criminal investigations, which consume much- needed funds for a painstaking legal process. If charged, either civilly or criminally – or both – the costs mount exponentially, and if an entity or employee(s) is found responsible, or guilty of violations, hefty fines, public embarrassment, loss of reputation, suspensions and/or loss of professional licenses and, in some cases, jail, are the unfortunate consequences.
Unfortunately, we have had to help too many “triage clients” – those that have already sustained damage, which then must be contained. That is why it is important for the health care industry to get out in front of this issue in order to prevent being an easy target for unscrupulous or misguided individuals or vendors who are looking to profit from fraud in the guise of “saving costs.”
Health care fraud is generally defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or to some other person or entity who is similarly not entitled to the benefit.