Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Fraud”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 91 records · Page 5Linked to original sources
PubMed1999

Health care providers and fraud investigations: what can you do when the government changes the rules in the middle of the game?

Mr. Rountree addresses the federal government's multi-pronged attack on health care fraud and focuses on the options available to health care providers who are under investigation by the government. The article proposes three potential responses to fraud investigations, including: (1) lobbying the government for relief; (2) suing the government; or (3) waiting to defend or settle the fraud action. After analyzing each method, Mr. Rountree concludes that an aggressive lobbying campaign is likely to be the most successful of the three possible provider responses.

American Hospital Association↗
PubMed2000

Fraud. What is the evidence?

The home health industry complains that Medicare fraud and abuse initiatives and legislation, namely, Operation Restore Trust (ORT), the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the Balanced Budget Act (BBA) of 1997 developed when home health care was vulnerable to reimbursement reductions from Medicaid and commercial insurers, particularly Health Maintenance Organizations. Additionally, it contends that the Health Care Financing Administration (HCFA) founded these initiatives on controversial government studies showing high rates of home health fraud and abuse and inappropriate assumptions that rising costs were indicative of fraudulent activities (Sarraille & William, 1998). We summarize reasons why the home health industry became a focus for enhanced Medicare fraud and abuse reduction efforts by HCFA and provide evidence supporting enforcement actions by HCFA's partners.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

An analysis of one potential form of health care fraud in Canada.

Health insurance fraud is a potential source of expense, injustice and adverse events in medical care. We examined one type of such fraud: false claims for prescription benefits after the death of the beneficiary. Of 335,536 elderly people in Ontario who died between Jan. 1, 1991, and Jan. 1, 1997, we identified 113 for whom 1 or more prescription drug benefit claims (about 1 per 3000 deaths) were submitted more than 1 year after their death. Claims for expensive medications were rare, as were those for addictive medications. Our findings suggest that this type of health care fraud occurs infrequently and that countermeasures are unlikely to substantially reduce medication abuse in Canada.

Drug Prescriptions↗
PubMed2003

Fraud and fiduciary liability.

All employee benefit plans are potential targets of fraudulent schemes. Smaller plans are targeted by unscrupulous brokers and promoters selling fraudulent policies; plans large enough to be self-insured face greater risks of fraud by providers and participants misrepresenting claims. Plan trustees, administrators and consultants should be alert to the many ways fraudulent schemes manifest themselves and to the legal remedies available; establish investigative programs to detect and discourage fraud; and promote education and plan incentives for participants to report fraud.

Criminal Law↗
PubMed2006

RHIOs--build in healthcare fraud management from the beginning.

This article presents the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology's field-based research on the use of Health Information Technology to Advance and Expand Healthcare Anti-Fraud Activities.' The authors of this article directed and performed this research under contract to the Foundation of Research and Education of AHIMA. There is a tremendous potential to reduce healthcare fraud and achieve substantial financial benefits using a nationwide health information network with interoperable electronic health records. To achieve these benefits, there must be interoperability among providers and between providers and payers. The article will provide recommendations for regional health information organizations to incorporate healthcare fraud management in their early designs.

Computer Communication Networks↗
PubMedDate not supplied

Fed up with fraud.

The national cost of health care reached 1.9 trillion dollars in 2004, or 6280 dollars for every man, woman, and child in the United States. And, although they are the exception rather than the norm, individuals intent on committing fraud and abuse are not far behind. According to the Centers for Medicare & Medicaid Services, the estimated annual loss to the government and health insurers from fraud continues to exceed 100 billion dollars. In a recent semiannual report to Congress, the Department of Health and Human Services (HHS) Office of Inspector General announced expected recoveries of 1.02 billion dollars for the first half of fiscal year 2006. At this rate, less than 5 percent of the losses from fraud and abuse are recovered annually.

Delivery of Health Care↗
PubMed1987

Patient confidentiality statutes in Medicare & Medicaid fraud investigations.

The Medicare and Medicaid programs have been burdened with health care providers' fraudulent and abusive practices since their implementation in 1965. To help states discover and prevent Medicare and Medicaid fraud, Congress has enacted statutes permitting access to patients' medical records in investigations of fraud. The majority of states have enacted physician-patient and psychotherapist-patient privilege statutes to protect confidential information from disclosure. Thus, the state's need for patient information conflicts with the patient's right of privacy. This Note discusses several court decisions that have wrestled with the tension between these two policies. The courts, after balancing the state interest in eliminating fraud against the patient's privacy interest, have often allowed disclosure of patient medical records. Although some courts have attempted to limit the extent of the information disclosed, few have set forth explicit standards to protect patient records from unwarranted disclosure of confidential information. This Note suggests guidelines for courts, legislatures and health care providers to uniformly limit the extent of this disclosure.

Confidentiality↗
PubMed1983

Fraud and science.

In the past decade fraud, cheating, forged experiments, and plagiarism have been discovered in fields ranging from biomedical research to psychometrics. Scientists have reacted by attempting to deny and minimize the problem. I believe that we should recognize that the phenomenon is not rare nor to be explained as a result of individual pathology. I look at some incidents in the history of science, give a taxonomy of fraud, and draw some morals about ways in which we might try to decrease the incidence of scientific fraud.

Crime↗
PubMed1997

Health care fraud: a growing problem.

Individuals and facilities convicted of health care fraud are likely to be excluded from participating in any federal health program. Knowingly disregarding the truth by submitting false claims is one type of fraud that is punishable by law--from a stiff fine to a lengthy imprisonment. Understanding the types of fraud in the health care context helps prevent abuse and liability.

Delivery of Health Care↗
PubMed1998

[Billing fraud from the viewpoint of the federal health insurance society].

During the past ten years, there has been a controversy among the German registered physician about settlement fraud-then outraged, now calling for criminal proceedings and an investigation by the public prosecutor. This is due to the fierce competition in a system of dense medical representation. Economically, any settlement fraud in the compulsory health insurance damages the colleagues, not the health insurance. An assessment of remuneration settlements under criminal law reveals the following: there is only one premeditated, punishable settlement fraud. Before demanding criminal proceedings which result in investigations by the public prosecutor, the society of panel doctors has to decide whether there is a case of premeditation or negligence. The society must be aware of the consequences for the physician. Types of deficit settlement: (1) settlement of services not rendered; (2) settlement of services not rendered personally; (3) false settlement of services rendered; (4) uneconomical settlement of services. Whether the latter can lead to criminal investigation, is still controversial. Within the medical profession, however, disciplinary action as well as proceedings for the cancellation of the licence can be requested.

Fees, Medical↗
PubMed1998

[Billing fraud from the viewpoint of the state attorney].

The so-called settlement fraud includes not only charging for unrealized services but also the charging of realized services that must not be charged as well as intended uneconomical behavior. Victim of this kind of fraud is either the privately paying patient or the society of panel doctors and, thus, every correctly charging physician when legal health insurances are involved. The perpetrator may be fined or imprisoned. Other punishments may include professional ban, revocation of the license, and compensation. Weak spots of the system encourage fraud. Without effective control mechanisms and self-administration, more and more physicians do not meet the confidence and the special responsibility necessary for the settlement system of our health insurances.

Fees, Medical↗
PubMed2006

[Fraud in biomedical literature].

The basic ethical principles in science are internationally recognised in all disciplines of science. The first among these is honesty--both towards oneself and towards others. The betrayal of this principle can be seen as deviant behaviour, which may result in the most serious violation of the high ethical standards of science--scientific fraud. Fraudulent behaviour in biomedical sciences is particularly damaging, since all diagnostic and treatment decisions are based on what is published in medical literature. The betrayers of science undermine, to a great extent, the public trust in science, and may destroy the confidence scientists have in each other as well, which is a grave danger to science itself. In this article, several high profile cases of scientific fraud--involving falsification, fabrication of data, and plagiarism--are described. The damaging effect they had on both science and the scientific community led to the codification of the concept of Good Scientific Practice (GSP)--an international quality standard for designing, conducting, recording, and reporting research. The concept of GSP sets internationally valid benchmarks for quality assurance, and also provides safeguards against scientific dishonesty and fraud.

Biomedical Research↗
PubMed1998

[Fluorescence microscopy for detection of frauds in ground coffee].

Currently, frauds in ground coffee are detected with traditional microscopy, which is a tedious and not very precise method. Therefore, a more efficient and rapid microscopical method based on fluorescence, was proposed. For the microscopy analysis, pure coffee was compared to coffee samples adulterated with rye, barley, corn and wheat at 2.5, 5.0, and 10.0% levels. Starch granules were detected and identified immediately with fluorescence microscopy, in the adulterated coffee mixtures, quite different from optical microscopy where no frauds were detected with certainty. The suggested fluorescence method for the detection of cereal frauds in coffee was found to be more efficient and precise than the current official one.

Coffee↗
PubMed2003

[A case of fraud in a neurological pharmaceutical clinical trial].

This paper describes the laborious and lengthy path to clarification and disclosure in a case of fraud in a neurological pharmaceutical clinical trial in the Netherlands. A Dutch neurologist was suspected of irregularities within the context of the 'European stroke prevention study 2' (ESPS-2), a multicentre study into medicinal prophylaxis in patients who had suffered a stroke. The Netherlands Society of Neurology (NVN) established an independent inquiry committee for further investigation of the case. The identity of 425 of the 438 patients (97%) included in the trial by the neurologist could be retrieved. The majority of these patients were known to the neurologist with cerebral infarct. For a sample of 115 patients, the general practitioners (GPs) were contacted by means of a questionnaire. Ninety percent of the responding GPs were unaware of their patients' participation in the pharmaceutical clinical trial. A total of forty patients were asked by their GP about participation: 36 (90%; 95%-CI: 76-97) indicated that they had not participated in the trial, and 4 could not remember. The committee concluded that the neurologist had committed fraud, in the sense that he had used the names of existing patients without these patients actually being enrolled in the study. The report of the independent committee was not made public; the committee and the NVN board differed in opinion on the interpretation and implications of the agreements regarding this subject. Following prolonged legal action, the regional Disciplinary Board suspended the neurologist from practice for one year and the court of law sentenced him to 180 days imprisonment or a fee of 130,000 Euro. Based on the experience gained from this case, recommendations in case of suspicion of fraud are discussed, such as the timely appointment of an independent inquiry committee and the establishment of unambiguous agreements regarding the disclosure of the results of the investigation. Possible legal implications should be considered in advance by the organisations involved; statutes should provide regulations for procedural rules. In the Netherlands there now exists a National Body for Scientific Integrity and a committee for the Scientific Integrity of Healthcare Research to prevent scientific misconduct and to stimulate reporting and appropriate handling of this problem.

Clinical Trials as Topic↗
PubMed2005

Ethics and fraud in science: a review of scientific misconduct and applications to craniofacial research.

The purpose of this article is to review and discuss the occurrence of fraud in biomedical research and analyze the definition, origin, and various forms of scientific misconduct. Fraud in research most often involves reporting data for which no records of experiment or population are present; manipulating research materials, equipment, or procedures to arrive at the desirable result; adding, changing, or omitting results, which positively or negatively relate to the hypothesis that the research intends to test; and incorporating ideas, statements, procedures of others' work without permission and appropriate credit to the source. The etiologic factors contributing to this deviant behavior, and measures taken by relevant bodies to eliminate this phenomenon are discussed. Ethical and integrity aspects of craniofacial research are explored and a set of criteria to facilitate rigorous assessment of the integrity of clinical and basic research protocols is proposed. These include (1) an integrity-focused training of researchers to adhere to specific laboratory procedure and tactics which discourage fraud; (2) appointment of external reviewers to detect unusual and suspicious experimental process or data patterns; and (3) encouragement of multicenter trials. Although it is widely recognized that the sole determinant of scientific misconduct is the individual investigator's integrity, a number of precautions may effectively reduce the prevalence of this event, which may affect the status and trends of biomedical research in general.

Bioethical Issues↗
PubMed1988

The detection of fraud and fakery.

Fraud is often found in science, especially in what is termed, 'fringe science'. There are several reasons why scientists should be aware of the fact that they, too, can be deceived, both by subjects in experiments and by themselves. The will to believe is strong even among 'hard-headed' academics, and is often the factor that causes them to publish results that do not stand up to subsequent examination and/or attempts to replicate. In some cases, scientists would be well advised to consult with such experts as conjurors, when skilled frauds are in a position to mislead them.

Crime↗
PubMed2003

What home healthcare nurses should know about fraud and abuse.

Home care nurses provide a critical link in all services provided by a home health agency. This article outlines basic information nurses can use to understand fraud and abuse regulations, see the importance of corporate compliance programs, and recognize the potential impact a focus on fraud and abuse has on their practice.

Community Health Nursing↗
PubMed2004

Avoiding charges of fraud and abuse: developing and implementing an effective compliance program.

During the last decade the federal government has made investigation of healthcare fraud and abuse a priority. Increasingly, nurses and skilled nursing organizations have been at the center of fraud and abuse cases. The authors examine data of sanctioned nurses obtained from the Office of the Inspector General. Nurses are most frequently sanctioned for license violations, drug convictions, and patient neglect.

Facility Regulation and Control↗