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PubMed1997

Fraud worries insurance companies but should concern physicians too, industry says.

The amount of insurance fraud is increasing in Canada. This should worry physicians, because all personal-injury claims must be substantiated by a medical certificate. The vast majority of physicians are honest and ethical, fraud investigators say, but some are being duped as patients scheme to cheat the insurance industry. In one sensational auto-insurance-fraud case, some Ontario physicians are being investigated about possible involvement in a self-referral scheme. Nicole Baer looks at insurance fraud and the challenges it poses for doctors.

Automobile Driving↗
PubMed1997

Fraud and abuse provisions in the Health Insurance Portability and Accountability Act: a guide to the new act for physicians.

The Health Insurance Portability and Accountability Act, many provisions of which became effective on January 1, 1997, will have a significant impact in the area of health care fraud and abuse. This article examines the fraud and abuse provisions of the new act from the point of view of the practicing physician. The greatest impact on the health care provider will come from the increased enforcement resources which will be available as a result of the act. The act also contains some particular substantive additions to health care fraud and abuse law which will be applicable to physicians, including provisions penalizing health care fraud, wrongful disclosure of individually identifiable health information, false certification for home care, and false statement to a health benefit program.

Fraud↗
PubMed2005

Scientific authorship. Part 1. A window into scientific fraud?

The examination of a single scientific manuscript seldom alerts scientists, reviewers, editors, and scientific administrators to the fabrication and falsification of data and information. This review shows that most documented cases of scientific fraud involve falsification (altering truthful information) and fabrication (inventing information where none previously existed). Plagiarism is much less frequent. The review of published accounts also shows that the publication of scientific papers containing recognizable fraudulent material is very low, probably less than 0.02% and extremely difficult to detect. Because most reported cases of fraud have involved research done at prestigious organizations with distinguished co-authors, and that is published in journals with exacting review processes, it becomes evident that some unscrupulous scientists are adept at fabricating and falsifying data. However, "significant" scientific fraud is detected when scientists repeatedly report results that cannot be independently verified, when colleagues report suspicious behavior, or scientific audits are performed. This review documents and compares many of the better-known cases of scientific fraud. Fraudulent behavior has served as the impetus for the scientific community to develop publication procedures and guidelines that help to guard against not only fraudulent behavior but also against other types of unethical or undesirable behaviors. A companion paper reviews the non-fraudulent issues associated with scientific publication.

Authorship↗
PubMedDate not supplied

Medical investigators' views about ethics and fraud in medical research.

The objective of this study was to ascertain the views and attitudes of medical investigators on medical ethics, and ethics and fraud in medical research. We sent postal questionnaires to all principal investigators whose study protocols had been assessed by their regional medical ethics committee for biomedical research (mid-Norway) in the years 1986-92 (n = 159). The response rate was 70% (n = 119). Some 80% agreed that ethical considerations had influenced their research and 12% that they would have had ethical scruples today about some of their previous projects. One in ten agreed that they might have achieved better results if they could have paid less attention to ethics. About 70% of the respondents found that the committee's comments were useful and relevant, but most agreed only in part. Around 85% agreed fully or in part that scientific quality is an important ethical element of any project and that researchers put more effort into their study protocol when they knew it would be evaluated by an ethics committee. One in six (18%) respondents agreed fully or in part that they had been exposed to scientific misconduct. Also, 27% knew about one or more cases of fraud or misconduct while 42% stated that this knowledge was not public. We concluded that ethics in medicine and medical research have an important and increasing role among investigators with little or no theoretical background and training in ethics. Scientific fraud and misconduct in medicine is a growing concern among researchers, who welcome a professional body that can manage allegations and cases of fraud.

Advisory Committees↗
PubMedDate not supplied

[Scientific fraud. A disease we find among ourselves].

Scientific fraud is not a problem exclusive to countries with high scientific development. Fraud does not necessarily mean invention of results, usurpation of ideas, manifest plagiarism or any other kind of serious scientific misconduct. Although more rare in countries where scientific production is more modest, pungent cases of scientific fraud also exist. However, less notorious cases of scientific misconduct are frequent and must be avoided. Examples of these less notorious sins are presented. The seriousness of scientific fraud is not only due to the fact that it may involve public funds, which could have been put to more useful purposes but, above all, because it violates scientific ethics and frustrates the final aim of science, the discovery of truth.

Ethics, Professional↗
PubMed2004

Workers' compensation fraud and the physician.

Some individuals in the health care system base their actions primarily on individual economic incentives rather than ethical and societal standards. These actions are considered fraudulent when they can be proven to have violated specific laws or statutes and can impact workers' compensation costs. Physicians and other health care providers involved in the management of workers' compensation claims may have little ability to affect employer or insurer fraud. Ethical and efficient practice style, in conjunction with the maintenance of clarity and objectivity in the evaluation of patient symptoms, can help to reduce the degree to which provider and patient fraud is allowed to develop and flourish. In understanding the factors that promote fraudulent behavior and being able to recognize and manage such behavior, health care providers may impact the perpetuation of fraud and its impact on the workers' compensation system.

Fraud↗
PubMed1999

Health care fraud.

The term health care fraud describes a variety of sins committed with more frequency and sophistication by a multitude of sinners. Because physicians are among those most likely to be affected by such fraud and efforts to prevent it, they may want to be familiar with this subject. Accordingly, certain aspects of health care fraud are reviewed from a physician's perspective.

Delivery of Health Care↗
PubMed2002

Will claims workers dislike a computerized fraud detector?

The computerized fraud detector (CFRD) assigns suspicion scores to questionable automobile insurance claims. Evaluators pilot tested this algorithm in three offices, comparing its effects with three matched offices. Observers uncovered that in two target offices and one comparison office, Millennium 2000 (M2K) also was being installed. The study design thus became as follows: Two offices had two interventions, one office had CFRD but not M2K, another office had M2K but not CFRD, and two offices had neither. Hierarchical linear models document that offices with both new computer systems will have the most unfavorable employee attitudes toward computerized fraud detection, followed by offices with only one new system. Employees with jobs of higher rank and employees not receptive to innovation will dislike computerized fraud detection. Implementation of one computer system, CFRD or M2K, may have minor negative fixed effects on employee attitudes, but their effects on the between-office variance are inconsequential.

Algorithms↗
PubMed1994

Process and detection in fraud and deceit.

There has been considerable interest recently in scientific misconduct. Although much has been written and discussed about specific cases, very little, if any, research has been carried out on the process of fraud. An understanding of this aspect can contribute much to methods of detection and lead to recommendations for preventing misconduct and for implementation of appropriate sanctions where fraud has been detected and proved. In this article I initiate a study of the process of fraud using a series of case studies. Hypotheses are generated by methods pioneered by Peirce and most recently developed and thoroughly discussed by Glaser and Strauss under the name of grounded theory. Some illustrations of what can be learned from such studies are included.

Biomedical Research↗
PubMed1997

Some legal and managerial strategies for managing healthcare fraud.

Healthcare fraud is an increasingly serious problem in the industry. The problem is complicated by disagreement over its basic causes and how it can be managed. Attempts to manage healthcare fraud introduce privacy issues as well as the proper role of the government. Even law enforcement officials appear to be undecided concerning jurisdiction and prosecution. Healthcare fraud is everyone's loss and will require the cooperation of all if it is to be controlled. The medical and legal as well as insurance organizations and the public must get involved.

Fraud↗
PubMed2000

The war on fraud and its effect on dentistry.

The fraudulent actions of a disreputable few people in the health care industry have caused enormous losses to government and private health care payers. Fraud can take a number of forms, but usually is based on some form of deceit. In response, law enforcement efforts have been aided by a number of recent anti-fraud statutes and significant new resources. The challenge to dentistry is to ensure that legitimate efforts to fight fraud do not unduly burden practitioners, the vast majority of whom are honest.

Costs and Cost Analysis↗
PubMed1986

The pathogenesis of fraud in medical science.

Using a recent case of research fraud as a basis, this article examines the pathogenesis of fraud in medical science and suggests some remedies. Among causative factors are the "pre-med syndrome," the extraordinary size of science (which makes supervision of young investigators difficult), and competition, both professional and economic. Remedies include more careful selection of personnel, reduction of excessively large research groups, and closer examination of work at all levels--the laboratory, the academic department, and the institution. Each institution should have in place mechanisms to investigate research fraud when it is uncovered.

Attitude of Health Personnel↗
PubMedDate not supplied

The need to combat clinical fraud.

This article explores the possibility that clinical fraud is being perpetrated on a daily basis at the interface between patient, nurse and others. This type of fraud might take place when nurses carry out, or fail to carry out, a clinical activity, in the way that they report the care delivered, or in the way that they conduct their relationships with colleagues. If any deception occurs before, during or following such activities then the nurse is guilty of fraud. If such fraudulent practice exists it could have negative consequences for patients and healthcare professionals. The authors examine the possible reasons for fraudulent practice.

Delivery of Health Care↗
PubMed1995

Home health agencies: targets of anti-fraud and abuse investigations.

Increased health care fraud and abuse investigations could result in home health agencies, and other targets, becoming politically acceptable casualties of war in the battle to balance the federal budget. To protect themselves, home health agencies would be well advised to conduct internal fraud and abuse audits on an annual basis and to develop corporate compliance plans (see Newsletter, Vol. 9, No. 7, July 1994, at 16, and next month's issue, which will discuss corporate compliance programs as well as the OIG's new voluntary disclosure program). In addition, purchasers of home health agencies should be especially vigilant of fraud and abuse problems during the due diligence phase of the acquisition and, if problems are discovered, should consider whether voluntary disclosure to the OIG and settlement of any resulting claims is an appropriate condition of closing.

Aged↗
PubMed1994

Recognizing the symptoms of employee fraud.

Unlike crimes that leave easily detectable physical evidence, employee fraud may be difficult to detect because often only symptoms of such crimes are readily apparent, and the symptoms may or may not signal actual fraud. This article discusses six categories of symptoms that indicate fraud may have been committed by an employee, and presents a case study example to illustrate symptoms auditors and financial managers should investigate.

Accounting↗
PubMed1994

Internal compliance systems are the best defense against fraud.

Healthcare reform a key issue for the Clinton administration, extends far beyond healthcare coverage concerns. With healthcare fraud estimated by Congress to total as much as $80 billion to $100 billion per year, uncovering fraud has become one of the administration's top priorities. With FBI and other investigators assigned to the problem, all areas of the healthcare industry will face increasing levels of scrutiny. This anti-fraud campaign will affect every type of provider, from large hospitals to small equipment vendors. An internal compliance program can help healthcare managers identify problems and avoid criminal prosecution.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Health care fraud and abuse. What physician executives need to know.

Fraud and abuse, which can occur in all industries, also exist in the health care industry. This problem is compounded by the reality that "American medicine, although undergoing evolution, now faces changes of a magnitude that has never before been encountered." These changes are creating new realities for physician executives and also new challenges. As there are changes in business practices, there will be changes in how fraud occurs in health care. Physician executives need to be sensitive to the possibility of fraud and abuse as an unwanted component in medical losses in managed care systems.

Fraud↗
PubMed1982

The fight against fraud and abuse: analyzing constituent support.

Most efforts to combat fraud and abuse have relied on a punitive-deterrent approach, assuming that higher penalties and stricter enforcement will both punish present offenders and deter potential ones. Social science perspectives, particularly that of systems theory, suggest that a more effective approach is prevention grounded in an understanding of the constituencies involved. Constituency analysis can identify the constellations of social and political power that sustain existing opportunities for fraud and abuse, and those that will support countermeasures. Illustrations are drawn from the author's experience with New York State's attempt at reform in nursing homes and with efforts by the General Accounting Office and the Office of Management and Budget to combat fraud and abuse in federal programs.

Consumer Advocacy↗