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Healthcare Fraud, Its Financial and Health Outcomes


The representatives of the general public refer to the healthcare facilities in order to receive some help. They entrust their lives and lives of people they care about to healthcare professionals but are not always treated decently because of attempts to circumvent the law. Such cases are considered by the HHS and Department of Justice fraud and abuse. According to several reports that described the situation in 2008, fraud expenditures constitute up to 15% of total annual costs, which equals approximately $170 billion.

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Health care fraud is defined as “knowingly, and willfully executes or attempts to execute a scheme…to defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by…any healthcare benefit program” (Rudman et al. 2). In this perspective, professionals are also talking about abuse, but this issue occurs unintentionally.

As a rule, fraud and abuse occur with billing, CPT codes, and provision of unrequired services. It is critical to prevent and report such cases because it leads not only to financial issues but also to adverse health outcomes and even deaths. Otherwise, healthcare facilities will not be able to provide the patients with the required services and the general public will not feel safe.

Fraud Issues, Psychosocial and Physiological Complications

There are different fraud issues that can be observed in the healthcare industry. These can be such things as changing claim forms in order to increase initial costs, alterations in treatment and histories, billing for the services and supplies that were not prescribed and provided, and billing for the services that were not required by the patient’s condition. The cases described in the article reveal submission of false information to Medicare, increasing costs of inpatient and outpatient care, biased Medicaid admission (reluctance to register individuals who really require such devices), performance of medically unnecessary surgeries, signing blank prescriptions, and insurance payment for healthcare services provided after the death of the person (“Common Types of Healthcare Fraud” 2).

Healthcare frauds have an adverse effect on the victim’s condition, as they cause stress and psychological problems that can influence an overall state of a person. Patients mainly suffer from financial loss that makes them feel insecure and undignified (“Fraud Statistics” para. 46). They feel lonely, embarrassed, or angry and frustrated. The physical state of the customers also may worsen due to both unnecessary services and poor psychological condition. Moreover, patients can become disabled or may even die because of the interventions that one received but never required or required but never received.

Ethical Issues

When calming that a healthcare fraud occurred, it is critical to identify whether the actions of the professional were ethical or not. In this perspective, it is significant for healthcare organizations to have established ethical principles. In this way, specialists will be obliged according to the code of ethics. Healthcare fraud can be noticed when professional violates such principles as respect patient’s dignity and rights, follow the standards of professionalism and be honest, respect the law and safeguard patient confidence, provide appropriate patient care, and support equal access to medical care (“International Code of Medical Ethics” para. 7). In this way, when a doctor prescribes unneeded surgery, one shows that he/she does not care about the patients and is not interested in their health condition. Except for that, this person fails to act as a professional and does not provide appropriate treatment. A doctor is not applying a customer-oriented approach when works, which leads to such consequences.

Advocating by Patient Rights

If I was a member of the team led by a doctor who is engaged in healthcare frauds, I would surely try to solve this situation and would advocate my patient rights. I believe that the professionals who work only to increase their income are not able to make a great contribution in the sphere of healthcare and should be replaced. Still, I would try to comprehend this doctor, hoping that one would alter the situation and would not commit such crimes again. I even believe that whistle boarding may be advantageous in this perspective as it can make the doctor stop practicing and defraud the patients.

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Sentencing and Fines

Personally, I think that all cases of healthcare fraud should be punished severely because they violate people’s right to health that is among the basic ones. To my mind, such a massive fraud scheme should be followed by a prohibition of further practice, a sentence in prison, and a fine. It is critical to show to the general public that the government does its best to make healthcare affordable to all people on the same conditions so that they will be not afraid of asking for help when it is needed.


Taking everything mentioned into consideration, it can be concluded that healthcare frauds have an adverse influence on the financial sphere and the patient’s physical and psychological condition. It is critical to prevent them and ensure safety to the general public. Training programs, computer-assisted coding, legal enforcement, data modeling, and data mining are likely to help with this. The reports should be made to gather the most important information about such cases so that they can be used in preventative measures. Healthcare professionals should notify the senior management team if such problems occur.


Common Types of Healthcare Fraud 2015. PDF file. Web.

Fraud Statistics 2012. Web.

International Code of Medical Ethics 2011. Web.

Rudman, William, John Eberhardt III, William Pierce and Susan Hart-Hester. “Healthcare Fraud and Abuse.” Perspectives in Health Information Management, 6.1 (2009): 1-24.

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