Idag är sjukvårdsbedrägerier överallt på nyheterna. Det förekommer utan tvekan bedrägerier inom vården. Detsamma gäller för varje företag eller strävan som berörs av mänskliga händer, t.ex. bank, kredit, försäkring, politik, etc. Det råder ingen tvekan om att vårdgivare som missbrukar sin position och vårt förtroende att stjäla är ett problem. Så även de från andra yrken som gör detsamma.
Varför verkar bedrägerier inom sjukvården få “lejonparten” av uppmärksamhet? Kan det vara så att det är det perfekta redskapet för att driva agendor för olika grupper där skattebetalare, sjukvårdskonsumenter och vårdgivare är duperingar i ett sjukvårdsbedrägerispel som drivs med “spets-of-hand” precision?
Ta en närmare titt och man bra kost finner att detta inte är något slumpspel. Skattebetalare, konsumenter och leverantörer förlorar alltid eftersom problemet med sjukvårdsbedrägerier inte bara är bedrägeri, utan det är att vår regering och försäkringsbolag använder bedrägeriproblemet för att vidareutveckla agendor samtidigt som de inte kan ta ansvar och ta ansvar för ett bedrägeri. problem de underlättar och låter blomstra.
1. Astronomiska kostnadsuppskattningar
Vilket bättre sätt att rapportera om bedrägerier än att presentera bedrägerikostnadsuppskattningar, t.ex
– “Bedrägeri som begås mot både offentliga och privata hälsovårdsplaner kostar mellan 72 och 220 miljarder dollar årligen, vilket ökar kostnaderna för sjukvård och sjukförsäkring och undergräver allmänhetens förtroende för vårt sjukvårdssystem… Det är inte längre en hemlighet att bedrägeri representerar en av de snabbast växande och mest kostsamma formerna av brott i Amerika idag… Vi betalar dessa kostnader som skattebetalare och genom högre sjukförsäkringspremier… Vi måste vara proaktiva i att bekämpa bedrägerier och missbruk inom sjukvården… Vi måste också se till att brottsbekämpande myndigheter har de verktyg de behöver för att avskräcka, upptäcka och bestraffa vårdbedrägerier.” [Senator Ted Kaufman (D-DE), pressmeddelande 10/28/09]
– General Accounting Office (GAO) uppskattar att bedrägerier inom sjukvården varierar från 60 miljarder dollar till 600 miljarder dollar per år – eller någonstans mellan 3 % och 10 % av sjukvårdsbudgeten på 2 biljoner dollar. [Health Care Finance News reports, 10/2/09] GAO är kongressens undersökande arm.
– National Health Care Anti-Fraud Association (NHCAA) rapporterar att över 54 miljarder dollar stjäls varje år i bedrägerier som utformats för att stoppa oss och våra försäkringsbolag med bedrägliga och olagliga medicinska avgifter. [NHCAA, webbplats] NHCAA skapades och finansieras av sjukförsäkringsbolag.
Tyvärr är tillförlitligheten hos de påstådda uppskattningarna i bästa fall tveksam. Försäkringsbolag, statliga och federala myndigheter och andra kan samla in bedrägeridata relaterade till sina egna uppdrag, där typen, kvaliteten och volymen av data som sammanställs varierar kraftigt. David Hyman, professor i juridik, University of Maryland, berättar att de allmänt spridda uppskattningarna av förekomsten av bedrägerier och missbruk inom sjukvården (som antas vara 10 % av de totala utgifterna) saknar någon empirisk grund alls, det lilla vi vet om sjukvårdsbedrägerier och övergrepp övervägs av vad vi inte vet och vad vi vet som inte är så. [The Cato Journal, 3/22/02]
2. Hälso- och sjukvårdsstandarder
Lagarna och reglerna som reglerar hälso- och sjukvård – varierar från stat till stat och från betalare till betalare – är omfattande och mycket förvirrande för leverantörer och andra att förstå eftersom de är skrivna på juridiska och inte klarspråk.
Leverantörer använder specifika koder för att rapportera behandlade tillstånd (ICD-9) och tillhandahållna tjänster (CPT-4 och HCPCS). Dessa koder används när man söker ersättning från betalare för tjänster som utförs till patienter. Även om de skapats för att tillämpas universellt för att underlätta korrekt rapportering för att återspegla leverantörernas tjänster, instruerar många försäkringsgivare leverantörer att rapportera koder baserat på vad försäkringsgivarens datorredigeringsprogram känner igen – inte på vad leverantören återgav. Vidare, öva byggkonsulter instruerar leverantörer om vilka koder som ska rapporteras för att få betalt – i vissa fall koder som inte korrekt återspeglar leverantörens tjänst.
Konsumenter vet vilka tjänster de får från sin läkare eller annan leverantör men kanske inte har en aning om vad dessa faktureringskoder eller tjänstebeskrivningar betyder när de förklarar förmåner från försäkringsgivare. Denna brist på förståelse kan leda till att konsumenter går vidare utan att få klarhet i vad koderna betyder, eller kan leda till att vissa tror att de fakturerats felaktigt. Den mångfald av försäkringsplaner som finns tillgängliga idag, med varierande täckningsnivåer, sätter ett jokertecken i ekvationen när tjänster nekas för icke-täckning – särskilt om det är Medicare som betecknar icke-täckta tjänster som inte medicinskt nödvändiga.
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