Healthcare fraud, waste, and abuse are significant issues in the US and cost billions of dollars annually. Waste and abuse refer to the unwarranted or excessive use of resources as well as intentional deception or misrepresentation of another person or institution for financial advantage. These problems have an adverse effect on patient outcomes and the standard of care in addition to having a negative financial impact on the healthcare sector. This paper will analyze how healthcare fraud, waste, and abuse affect healthcare expenses and offer remedies to deal with them and avoid them in the future.
Article Summaries
Healthcare fraud is an intentional act done to benefit financially. According to Ahadiat & Gomaa’s (2018) study findings, the scheme with the most excellent rating against Medicare is improper diagnostic or procedure reporting, whereas the scheme with the highest rating against private insurance companies is invoicing for unnecessary treatments. The findings of this study can help the government’s attempts to stop and detect fraud. Fraud and abuse have a direct negative effect on the use of medical services because they waste scarce resources and put patients at risk by giving them needless care or preventing them from receiving necessary medical care, which increases the risk of all-cause mortality and emergency hospitalization (Mackey et al., 2020). The technology framework and prototype for blockchain-based health care fraud and abuse are intended to provide a shared governance approach to combating health care fraud and abuse while simultaneously giving consumers the choice and power to take an active role in the claims verification process.
The goal of the paper by Stowell et al. (2018) is to educate readers on how widespread healthcare fraud is in the USA. Healthcare fraud continues to pose a severe threat to the US economy and the public despite increasing financing and enforcement efforts by the government (Stowell et al., 2018). Even while healthcare fraud cannot be eradicated, particular measures can be used to control these sophisticated fraud operations. According to the article by Thaifur et al. (2021), the majority of fraud perpetrators appear to be medical staff and providers in the nine articles that were analyzed. There are many different sorts of fraud, including duplicating claims and entirely unadministered or non-compliant medical actions.
Solutions to Address Healthcare Fraud, Waste, and Abuse
Increase Enforcement Efforts
Increasing enforcement activities is one way to fight healthcare fraud, waste, and abuse. To track down and prosecute people and organizations that participate in fraud, government agencies and regulatory bodies ought to cooperate. This can involve carrying out audits, inspections, and investigations in order to spot fraudulent activity and hold people accountable. Healthcare providers and insurance firms should endeavor to enhance their policies and procedures and fraud detection systems in addition to increased enforcement activities (Stowell et al., 2018). Using data analytics and other cutting-edge technologies can help to spot suspicious behavior and stop fraud before it starts.
Improve Transparency
Enhancing openness in the healthcare sector is another way to combat fraud, waste, and abuse in the sector. Precise and accurate disclosure of the services they offer and the charges connected with those services should be required of providers and health insurers. The cost of various treatments and care should be disclosed to patients, together with information on the competence and security of healthcare professionals. Enhancing openness can aid in reducing fraud and abuse by making it more straightforward for patients and insurance companies to spot irregular behavior (Thaifur et al., 2021). Patients can alert their insurance company or regulatory authorities to questionable behavior, and insurance companies can utilize transparency to see trends of fraud and take appropriate measures to stop it in the future.
Promote Education and Awareness
Promoting education and awareness among healthcare professionals, patients, and the general public is a third way to reduce healthcare fraud, waste, and abuse. Healthcare professionals should receive training on how to spot and stop fraud and abuse, as well as lessons on the value of moral conduct and the potential repercussions of engaging in an unethical action. Patients should be instructed on how to avoid fraud and abuse, including how to comprehend their insurance benefits, examine their medical bills, and file a complaint of any questionable activity (Thaifur et al., 2021). The general people should receive education about how healthcare fraud, waste, and abuse affect the healthcare sector and how crucial it is to stop these problems. Encouraging patients and providers to make more educated healthcare decisions, raising awareness, and promoting education can also assist in cutting down on waste and irrational spending. Patients who are aware of their treatment options may be more inclined to select less expensive solutions, and healthcare professionals who are knowledgeable about the prices of various therapies may be more inclined to suggest affordable alternatives.
Implement Healthcare Reforms
Finally, putting healthcare legislation into action can aid in addressing healthcare fraud, waste, and abuse. The Center for Medicare and Medicaid Services (CMS) Fraud Prevention System and the False Claims Act were both expanded as part of the Affordable Care Act (ACA), which had several provisions targeted at decreasing healthcare fraud and abuse (Mackey et al., 2020). The improvement of care coordination, the promotion of the use of electronic health records, and the expansion of value-based payment models are possible reforms. These changes can reduce waste and wasteful spending while simultaneously enhancing the quality of care.
Conclusion
Healthcare fraud, waste, and abuse are serious issues that significantly affect patient outcomes and healthcare expenses in the United States. These problems can be addressed and avoided in the future by increasing enforcement efforts, enhancing transparency, fostering education and awareness, and enacting healthcare reforms. People can build a more effective healthcare system that offers high-quality care to all patients at an affordable price by cooperating to fight fraud, waste, and abuse.
References
Ahadiat, N., & Gomaa, M. (2018). Healthcare fraud and abuse: An investigation of the nature and most common schemes. Journal of Forensic and Investigative Accounting, 10(3), 428-435. Web.
Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating health care fraud and abuse: Conceptualization and prototyping study of a blockchain antifraud framework. Journal of medical Internet research, 22(9). Web.
Stowell, N. F., Schmidt, M., & Wadlinger, N. (2018). Healthcare fraud under the microscope: improving its prevention. Journal of Financial Crime, 25(4), 1039-1061. Web.
Thaifur, A. Y. B. R., Maidin, M. A., Sidin, A. I., & Razak, A. (2021). How to detect healthcare fraud? A systematic review. Gaceta Sanitaria, 35, 441-449. Web.