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PubMed1997

Fraud is fraud.

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Duplicate Publications as Topic↗
PubMed1996

[Good practice is a means for preventing fraud in clinical research].

The aim of this article is to present the findings concerning scientific fraud that have appeared in case reports. Deliberate scientific fraud does exist. The fact that most of the documented cases have occurred in Anglo-Saxon countries seems to indicate, not that Anglo-Saxons are more prone to scientific fraud, but rather that they have been more successful in bringing it to light. Since 1974, 72 cases have been reported in which there was either conclusive evidence or else a strong presumption of fraud: one case in Switzerland, one in Canada, four in Australia, 14 in Great Britain and 52 in the United States. Fraud is estimated to affect 2-5% of clinical research trials. Referees and readers do not set out to track fraud. The American Commission has proposed the terms "misappropriation, interference, misrepresentation" to define fraud. Voluntary fraud is hidden and its detection delayed. In well-known cases, more than 5 years elapsed before the information reached the scientific community. Whistle blowers must sustain a determined effort to denounce fraud over a period of 1-3 years if they are to trigger an investigation. Some whistle blowers have themselves been accused of fraud because their claims proved so embarrassing. Fraud can lead to severe accidents and generate expenditure that those responsible, or the institutions they work for, will never pay back. Frauders are usually motivated by the desire for material gain or the desire to become well-known. The motivating factor may be personal enrichment, or a need for funds for a not-for-profit association. People found guilt of fraud always have good excuses. Some simply do not realize what they have done. A knowledge of research methodology and critical appraisal methods can help to prevent fraud. Good clinical, laboratory and manufacturing practice can help to prevent misconduct and trickery. Audits and inspections are another essential means of combatting fraud.

France↗
PubMed1996

Health care fraud control: understanding the challenge.

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.

Crime↗
PubMed1991

Employer strategies to combat health care plan fraud.

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.

Data Collection↗
PubMed1999

The role of biostatistics in the prevention, detection and treatment of fraud in clinical trials.

Recent cases of fraud in clinical trials have attracted considerable media attention, but relatively little reaction from the biostatistical community. In this paper we argue that biostatisticians should be involved in preventing fraud (as well as unintentional errors), detecting it, and quantifying its impact on the outcome of clinical trials. We use the term 'fraud' specifically to refer to data fabrication (making up data values) and falsification (changing data values). Reported cases of such fraud involve cheating on inclusion criteria so that ineligible patients can enter the trial, and fabricating data so that no requested data are missing. Such types of fraud are partially preventable through a simplification of the eligibility criteria and through a reduction in the amount of data requested. These two measures are feasible and desirable in a surprisingly large number of clinical trials, and neither of them in any way jeopardizes the validity of the trial results. With regards to detection of fraud, a brute force approach has traditionally been used, whereby the participating centres undergo extensive monitoring involving up to 100 per cent verification of their case records. The cost-effectiveness of this approach seems highly debatable, since one could implement quality control through random sampling schemes, as is done in fields other than clinical medicine. Moreover, there are statistical techniques available (but insufficiently used) to detect 'strange' patterns in the data including, but no limited to, techniques for studying outliers, inliers, overdispersion, underdispersion and correlations or lack thereof. These techniques all rest upon the premise that it is quite difficult to invent plausible data, particularly highly dimensional multivariate data. The multicentric nature of clinical trials also offers an opportunity to check the plausibility of the data submitted by one centre by comparing them with the data from all other centres. Finally, with fraud detected, it is essential to quantify its likely impact upon the outcome of the clinical trial. Many instances of fraud in clinical trials, although morally reprehensible, have a negligible impact on the trial's scientific conclusions.

Biometry↗
PubMed1997

Confidentiality and health insurance fraud.

BACKGROUND: Health insurance fraud committed by patients may be an increasing problem given the number of underinsured and uninsured people in the United States. Physicians recognizing acts of health insurance fraud perpetrated by patients face an ethical dilemma: should they disclose the incident to the insurance company, or protect patient confidentiality? OBJECTIVE: To explore physicians' attitudes toward the reporting of patient-initiated health insurance fraud. METHODS: Three hundred seven physician members of the American College of Physicians returned a mailed questionnaire that presented 6 case vignettes (3 variables) of patients who used a relative's insurance to obtain health care in the past. For each vignette, respondents were asked whether the treating physician should report insurance fraud to the health insurance carrier. RESULTS: Sixty-three respondents (20.7%) indicated that physicians should report all the patients presented in the vignettes, while 45 (14.8%) indicated none should be reported; the rest indicated that the decisions to-report should be based on the characteristics presented, with acute vs terminal illness (P < .001), history of fraud (P < .001), and wealth of the patient (P < .001) all causing physicians to be more likely to report the patient to the health insurance carrier. Multivariate analysis demonstrated that type of practice (P = .04) and respondents' experiences with insurance fraud (P = .03) had significant effects on the willingness to report patients. CONCLUSIONS: Physicians are divided about whether to report patients who have committed insurance fraud. Their decisions to report insurance fraud are influenced by their attitudes and demographic features, as well as by patient factors.

Attitude of Health Personnel↗
PubMed2002

Implications of fraud and abuse in interventional pain management.

The federal government has enacted a comprehensive strategy to fight healthcare waste, fraud and abuse. As a result of the federal government's comprehensive strategy, in 2002, the Office of Inspector General announced that improper Medicare payments to doctors, hospitals and other healthcare providers declined 54% from the fiscal year 1996 to the fiscal year 2001. The Office of Inspector General in its 2002 work plan focuses on procedure coding for outpatient services billed by hospital and doctor, coding for evaluation and management services in physician offices and conditions under which a doctor's bill is "incident to" services or supplies among other things. The distinction between fraud and abuse can be very important in determining the potential fines and penalties that might apply, even though it is not clear. Fraud is much more serious than abuse. The degree of intent by the individual or entity under investigation is often the determining factor. The most commonly used statutes for prosecuting or facilitating such a prosecution of healthcare fraud or abuse include HIPAA of 1996, the False Claims Act, healthcare fraud, theft or embezzlement, obstruction of criminal investigations of healthcare offenders, the False Statement Statute, mail and wire fraud statutes, the Social Security Act Civil Monetary Penalties, criminal penalties, and/or Stark laws. This review focuses on various aspects of implications of fraud and abuse in interventional pain management practices including various activities of potential fraud and abuse.

Journal Article↗