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PubMed2001

Health care fraud and abuse: market change, social norms, and the trust "reposed on the workmen".

Health care fraud and abuse reportedly account for 10 percent of total spending on health care, or about $120 billion per year. Not surprisingly, Congress has granted fraud control personnel sweeping powers with which to attack the problem. Unfortunately, effectively addressing health care fraud is exceedingly complicated, particularly in light of recent major changes in the medical marketplace and the social context of such conduct. Broadly speaking, physicians view such conduct as essential to ensure high-quality care; program administrators view it as the price of the program; fraud control personnel view it as criminal misconduct; and the public's view depends greatly on who is benefitting. Social norms regarding health care fraud vary among these groups as well. The article examines the practical and theoretical challenges associated with attacking health care fraud and the merits of the current fraud control regime in light of these considerations.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1977

Control of fraud and abuse in Medicare and Medicaid.

This Comment explores issues concerning the control of fraud and abuse in health programs financed with public funds, specifically the Medicare and Medicaid programs. It summarizes the nature, scope, and possible causes of what some regard as a fraud and abuse "crisis," and points out the difficulties and obstacles facing those who attempt to develop legislative and executive action aimed at controlling fraud and abuse. Recent federal initiatives in fraud and abuse control are examined, and a brief summary of key provisions of H.R. 3 (the Medicare-Medicaid Anti-fraud and Abuse Amendments, which may prove to be a landmark piece of legislation in this area) is provided. The author emphasizes that more effective control of fraud and abuse is necessary if further expansion of government financing of health programs, including national health insurance, is to occur in the near future. At the same time, caution must be taken not to neglect the appropriate use of other mechanisms necessary for reducing the costs of medical care and improving its quality. In addition, it is likely that efforts to stem fraud and abuse will raise important medicolegal and public policy issues that will require careful interdisciplinary consideration.

Crime↗
PubMed1985

Medical students' attitudes on physician fraud and abuse in the Medicare and Medicaid programs.

The authors in this paper report the findings of a survey of medical students at the University of California, Irvine, California College of Medicine regarding their views on the Medicare and Medicaid programs and on the problem of fraud and abuse in these government medical benefit programs. The students were asked their views on four issues: (a) the quality of various aspects of Medicare and Medicaid; (b) the seriousness and prevalence of physician fraud and abuse in the programs; (c) the punishment that should be given to violators; and (d) the causes and prevention of fraud and abuse in Medicare and Medicaid. They viewed fraud and abuse as serious but not as being widespread. They believed that physicians who violate program regulations are not likely to be punished by official agencies. They favored moderate penalties for violations. Explanations offered by the students for fraud and abuse focused on physicians' attitudes and motivations as well as on the structure of the Medicare and Medicaid programs.

Attitude of Health Personnel↗
PubMed2006

Consumer fraud and the elderly: a review of Canadian challenges and initiatives.

Financial abuse is the most common type of elder abuse. Consumer fraud, a form of financial abuse perpetrated by criminals who do not know the victim, is not well studied. Seniors represent a disproportionate percentage of the victims of consumer fraud. This article reviews the data on the prevalence of consumer fraud (primarily telemarketing scams) in Canada. It examines the reasons why Canadian seniors are targets of fraud. It also describes many unique initiatives developed at the local, provincial and national level in Canada to educate seniors and those who care for them about the types of scams and the risks of fraud.

Aged↗
PubMed1987

Practitioner fraud and abuse: a public policy status report.

In summary, a public policy to get rid of practitioner fraud and abuse has been established. It resulted initially from the changing attitude of the electorate on spending for social as well as health service programs. It is reflected by the congressional enactment of new laws against practitioner fraud and abuse, i.e., the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 and the Civil Money Penalties Law of 1981. It has been implemented through the prosecution of numerous practitioners involved in fraudulent activities and abuses using the new laws as well as many others, including the False Claims Act of 1963 and the fraud penalties codes recognized under the Federal Old Age, Survivors and Disability Insurance Act. The ultimate success of this public policy, however, will certainly depend, at least in part, on our ability to obtain an objective and realistic analysis of the degree of fraud and abuse in these programs, as well as to define the characteristics of "Medical Mills" and to determine to what extent they still exist. Finally, if this public policy is to mature, it must follow a path that assures that we do not disrupt or hamper the delivery of health care services to our poor and elderly populations through the needless introduction of regulatory requirements or legal excesses.

Crime↗
PubMed2002

Common fraud experienced by the elderly: findings from a 1998 survey in Houston, Texas.

This study investigated the types and frequency of frauds experienced by seniors of different ethnic groups attending senior centers in 1998. Two hundred seniors aged 65 years or older were surveyed at 6 selected senior centers in Houston, Texas, and were asked to report the occurrence of frauds over the past year. Forty-three seniors (27%) responded that they had been victims of frauds, such as fake free prizes, work around the house, products to improve health and beauty, false insurance coverage, fees paid to attorneys and accountants, appliance repairs, credit restoration, investment participation, magazine subscriptions, and training courses. The prevalence of a reported experience with frauds by race or ethnicity was 47% of Hispanic seniors, 35% of African Americans, 25% of non-Hispanic whites, and 10% of Asians. The multivariate analysis adjusting for demographic factors showed that risk of experiencing frauds had no statistically significant association with age, gender, ethnicity, or marital and living status.

Aged↗
PubMed2003

Health care fraud: recent developments and timeless advice.

Health care fraud has gained increased attention at both the state and federal levels in recent years. The $875 million criminal settlement by TAP Pharmaceutical Products, Inc, in October 2001 and subsequent indictments of physicians involved with the alleged HCA Medicare fraud conspiracy highlight the fact that physicians who are unaware of any wrongdoing may get dragged into the government's battle. The various laws and overlapping enforcement agencies can be complex and daunting to a physician who is falsely accused. This article provides a brief overview of three relevant federal health care fraud statutes: the Prescription Drug Marketing Act, the Medicaid Anti-Kickback Statute, and the False Claims Act. The article also briefly discusses the Texas Medicaid Fraud Prevention Act and the roles of various state agencies responsible for the detection and prevention of health care fraud. Finally, the article provides practical advice about the investigate process and what every prudent physician should do if under investigation.

Fraud↗
PubMed2004

[Fraud in fundamental and clinical investigations. The necessity for an independent commission for scientific integrity].

Scientific misconduct takes various different forms and is real fraud only if there is evidence of intention. There are many forms of scientific dishonesty ranging from very serious to just below the limit of what is permissible, and it occurs at all stages of scientific research. Tracing fraud is by no means easy and its discovery is often only accidental. American, British and Dutch incidences are reported. We know the causes of fraud to be profit-seeking in all its forms, vanity and sloppy research practice. Oddly enough, the consequences of fraud are often more advantageous to the perpetrators than to the whistle-blowers. Literature becomes polluted and faith in scientific knowledge is damaged. In summary the measures and sanctions employed to combat fraud in the United States, Scandinavia, the United Kingdom and The Netherlands, are described. In The Netherlands are recently two commissions appointed. Points of discussion include: a governmental or other commission organized at a national or regional level, what protocol should be implemented, should the commission have powers of sanction, for how long should the members of commission be appointed and how is the extent of their liabilities to be decided upon?

Ethics, Research↗
PubMedDate not supplied

Scientific fraud: definitions, policies, and implications for nursing research.

Scientific research typically has been founded on high ethical standards established by researchers in academia and health care research institutions. Scientific fraud, an act of deception or misrepresentation of one's own work, violates these ethical standards. It can take the form of plagiarism, falsification of data, and irresponsible authorship. Scientific fraud has been attributed to misdirected attempts to attain high levels of personal and professional success. Researchers so prone commit scientific fraud in a search for promotion, status, tenure, and the obtaining of research grants. To divert scientific fraud, three recommendations are suggested: (1) socialize prospective nurse researchers into an atmosphere where intellectual and professional integrity prevail; (2) have established nurse researchers serve as role models and mentors who can educate the neophyte researcher about the ethics of research, including scientific fraud; and (3) emphasize and reward quality in research and publications, rather than quantity.

Ethics, Professional↗
PubMedDate not supplied

Health care fraud and abuse.

In recent years, health care fraud and abuse have become major issues, in part because of the rising cost of health care, industry consolidation, the emergence of private "whistle-blowers," and a change in the concept of fraud to include an emerging concern about quality of care. The 3 types of conduct that are generally prohibited by health care fraud laws are false claims, kickbacks, and self-referrals. False claims are subject to several criminal, civil, and administrative prohibitions, notably the federal civil False Claims Act. Kickbacks, or inducements with the intent to influence the purchase or sale of health care-related goods or services, are prohibited under the federal Anti-Kickback statute as well as by state laws. Finally, self-referrals-the referral of patients to an entity with which the referring physician has a financial relationship-are outlawed by the Ethics in Patient Referral Act as well as numerous state statutes. Consequences of violations of these laws can include, in addition to imprisonment and fines, civil monetary penalties, loss of licensure, loss of staff privileges, and exclusion from participation in federal health care programs. Federal criminal and civil statutes are enforced by the US Department of Justice; administrative actions are pursued by the Department of Health and Human Services' Office of Inspector General; and all state actions are pursued by the individual states. In addition, private whistle-blowers may, acting in the name of the United States, file suit against an entity under the False Claims Act. Enforcement of health care fraud and abuse laws has become increasingly commonplace and now affects many mainstream providers. This trend is likely to continue.

Disclosure↗
PubMed1991

Difference in scientists' discourse about scientific fraud and impropriety.

Fifty-one practising scientists made Q-sorts of 90 statements relating to scientific fraud and impropriety. Principal components analysis identified two major groups. Members of the first group (N=18) seemed to support the standard, or received, view about the nature of science and to interpret scientific fraud and impropriety in terms of the individual shortcomings of deviant scientists. Members of the second group (N=7) seemed to adopt a more critical position about the nature of science and were more likely to construe scientific fraud and impropriety as anticipated aspects of the operation of a human social institution. Some implications of these findings for an understanding of the current debate on scientific fraud and impropriety are considered.

Attitude↗
PubMed2006

Blowing the whistle on healthcare fraud: should I?

PURPOSE: The purpose of this article is to explore some of the factors involved when a nurse practitioner (NP) is confronted with a healthcare fraud situation. Ethical concepts and decision-making strategies are provided, as well as practical legal considerations. DATA SOURCES: Government Internet Web sites; healthcare management, ethics, and nursing journals. CONCLUSIONS: There are many forms of healthcare fraud. Healthcare fraud saps financial resources from the healthcare system and from individuals. The decision to blow the whistle on a colleague or organization is not an easy one and has potential for great discomfort. There are ethical decision-making strategies and practical considerations for the process of whistle-blowing should it become necessary. IMPLICATIONS FOR PRACTICE: NPs may be confronted daily with billing and reimbursement issues. Being prepared to recognize healthcare fraud and knowing the ramifications of whistle-blowing are important tools to have in one's practice repertoire.

Attitude of Health Personnel↗
PubMed2006

Health care fraud and abuse laws.

CONTEXT: Health care fraud and abuse enforcement actions have significantly expanded in number and scope during the past several years. The Department of Health and Human Services Office of Inspector General named review of in-office pathology services a critical priority in its 2005 Work Plan. As providers of pathology and laboratory medicine services, pathologists need to be aware of the potential impact of these laws on their practices. OBJECTIVES: To review the major statutes and regulations underlying most federal investigations and prosecutions of health care fraud, with a special emphasis on their relationships to pathology practice. DESIGN: The authors reviewed pertinent federal statutes, regulations, and other documents, along with relevant legal literature. RESULTS: The health care fraud and abuse laws are complicated and potentially impact pathology practice in unforeseen ways. CONCLUSIONS: The health care fraud and abuse laws are complex and often counterintuitive. The penalties for violation of these laws are severe. Because they may impact many areas of pathology and laboratory medicine practice, pathologists are advised to consult experienced legal counsel prior to embarking on potentially suspect health care arrangements.

Fraud↗
PubMed1993

Long distance telephone fraud and abuse.

The article discusses the difference between abuse and fraud, the cost of fraud to a business, how fraud is accomplished, and ways to combat long distance fraud.

Commerce↗
PubMed1999

AICPA standard aids in detecting risk factors for fraud. American Institute of Certified Public Accountants.

The American Institute of Certified Public Accountants' Statement on Auditing Standards (SAS) No. 82, Consideration of Fraud in a Financial Statement Audit, requires independent auditors to obtain reasonable assurance that financial statements are free of material mis-statements caused by error or fraud. SAS No. 82 provides guidance for independent auditors to use to help detect and document risk factors related to potential fraud. But while SAS No. 82 suggests how auditors should assess the potential for fraud, it does not expand their detection responsibility. Accordingly, financial managers should discuss thoroughly with auditors the scope and focus of an audit as a means to further their compliance efforts.

Accounting↗
PubMed2001

Employee theft and fraud: bigger than ever and getting worse.

Fraud examiners and investigators say that employee theft is out of control, citing recent U.S. Chamber of Commerce figures that employees steal approximately $400 billion from businesses each year and an Ernst & Young survey showing that nearly 90% of organizations countrywide experienced some type of fraud in the 12 months prior to the survey. An additional undetermined amount is being reported lost because of external fraud committed by customers, vendors, and others having contact with a company or institution. Fraud experts interviewed for this report note that all sectors are targets--including retailers, hospitals and healthcare, the hotel industry, schools, and college campuses. In this report, we'll present the how's and whys of this development and also describe what one medical center is doing to stop thefts of medical equipment and computers.

Fraud↗
PubMedDate not supplied

Are you committing health care fraud under the False Claims Act? The answer may not be as simple as you think.

Health care fraud has a significant financial effect on the operations of the American health care system. Governments and insurers are intent on quashing such fraud and have instituted massive efforts to indict and punish offenders as well as recover major monetary awards. This article provides examples of fraudulent practices and details the definitions of fraud and abuse. In addition, it characterizes the concept of qui tam that allows whistleblowers to share in any financial awards. Finally, it highlights the importance of proper coding as a means of reducing the suspicion of fraud or abuse.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2004

Healthcare fraud and quality of care: a patient-centered approach.

This Article explores the intersection between quality of care and healthcare fraud by examining the extent to which quality-related fraud settlements benefit patients. The author argues that, although the protection of beneficiary health and welfare often is invoked by the federal government as one of the reasons for undertaking anti-fraud efforts, such considerations do not appear to play a large role in many of the settlements that are negotiated. While returning funds to the federal Treasury helps to ensure that the federal healthcare programs remain solvent and continue to serve beneficiaries in the aggregate, it may not adequately address harm to individual patients. Thus, the author concludes it may be time to explore new models of fraud settlements that can provide adequate compensation to the patients who may have suffered harm.

Compensation and Redress↗