Fraud: The Other Healthcare Debate

While politicians debate the state of healthcare in the U.S., it's easy to lose sight of a threat that is only worsening: healthcare fraud. The risk of corruption in the healthcare industry causes masses losses and theft every year, from patient, provider and insurance fraud (and in some cases, a combination all three).

In a recent Texas case, 16 people were indicted in a $60 million Medicare fraud scheme. According to an article from CBS DFW, the fraud centered around false claims by a company called Novus Health Services, most of which concerned hospice (end-of-life) care. As reported in "16 Texans Charged in $60 Million Medicare Fraud Scheme":

"The defendants are accused of submitting false claims for hospice services, false claims for continuous care hospice services, and recruiting doctors and healthcare facilities forpatient information of individuals ineligible for hospice in return for money.

The defendants would allegedly decide whether to place, keep, or discharge a patient from hospice depending on how it would affect Novus’s ability to bill Medicare."

In another disturbing case, physicians - those entrusted to take care of people, not rob them - committed both medical fraud and identity theft. This case happened in Puerto Rico, where three doctors conspired with a medical supplier to commit the vast fraud.

According to HealthIT Security, the fraud lasted six years, from 2007 to 2013. As reported in "Physicians Charged with Healthcare Fraud, Identity Theft in PR":

"The defendants reportedly “conspired with each other and with other individuals known and unknown to the grand jury to defraud Medicare,” according to a US Department of Justice release. The alleged scheme also occurred from on or about February 20, 2007 through on or about July 18, 2013.

'The federal charges stem from an alleged scheme whereby Javier Efraín Siverio-Echevarría, as owner of Equipomed Care Corp., a durable medical equipment company with offices in Hatillo, Puerto Rico, would use the personal identifying information of Medicare beneficiaries, to invoice Medicare for durable medical equipment that these beneficiaries did not need or to whom the equipment would not be delivered,' the statement explained."

These are just among the countless cases of healthcare fraud that are reported regularly in the U.S. (not to mention the world). As the debate over the future of healthcare in the country dominates the headlines, the question is: Where does combating and preventing healthcare fraud enter the discussion?

Politicians and industry leaders would be wise to make special provisions to help fight healthcare fraud in any new legislation, while protecting those controls that are already in place. To ignore the problem could mean a flood of losses in an industry already dealing with an increasing level of fraud risk.