Discussion Fraud and Abuse
Healthcare has evolved from caregiver-centered to being patient-centered. In the current dispensation, the patients have a voice on what they expect from the medical service provider and how their insurance is utilized vis-à-vis the kinds of services they receive. The current patients are also keen to understand how, why, and what they are given. Therefore, this has called for integrity on the healthcare front. Integrity is a vital matter in all sectors of administration and governance. Its expanse is unknown but effects are visible. Fraudulent practices have ensured derailed services and at times services not being rendered. In the healthcare sector, fraud as Melissa indicates involves deliberate conspiracy between medical staff, healthcare insurance firms, and medical service hospice (Kathleen, 2009) a phenomenon she refers to as ‘Abuse’. It could take the dimension of falsification of health information by the practitioner to receive ‘plump’ compensations for services not rendered and/or underpayments by the insurer for high-value services. Melissa further indicates that such practices led to the establishment of anti-fraud laws. I agree with her sentiment of necessity being the purpose for invention.
The health care sector has experienced a sense of duty and accountability, financially and in terms of service delivery through initiatives including Recovery Audit Contractors (RAC) and Pay for Performance. RAC could not be established at a better time. In this system, contractor-specific proprietary software is used to identify innate system flaws for it to investigate. These are erroneous allocations in the form of takebacks, overpayments, erroneous payments, and underpayments on claims among others.
In the pay for performance scheme, practitioners are rewarded based on services delivered and milestones achieved in everyday practice. These rewards and accountability schemes are put in place to ensure a motivated workforce that embellishes integrity. These two factors compound and guarantee better health care service outcomes for patients. Implementation of the Anti-Kickback Statute, the Stark Law, and the False Claims Act will temporarily work as deterrents to medical-related fraud but more innovative schemes have to be hatched as frauds are on the prowl. Additionally, the pay for performance should be better defined to prevent the entrapment of practitioners under the provisions of the Stark Law.
Response to Melissa
Melissa in her writings overemphasizes the impact of counter fraud laws on the deterrence of fraudulent minds. But is that enough? Does the enactment of such laws really deter fraudsters from indulging their trade? Of course not, a repeat offender will almost always be pulled into committing a crime of a more clandestine and complicated nature compared to previous acts. Emphasis should therefore not be placed on the formulation of new counter-fraud laws but the customization of the existing laws to be timely and evolve in a manner commensurate with the fraudsters’ mindsets. Decolonization of the fraud’s mindset is therefore key in the fight against fraud and abuse in the health care sector.
Response to Kianna Harris
In her argument, Kiana is quick to exonerate and absolve ‘abusers’ from impropriety responsibility. How is one crime smaller than another?. The perpetrator and the abate share equal responsibility to the crime. Kiana indicates that for fraud to be reduced and finally eliminated, a multi disciplinary approach has to be sought. I second her opinion that only through forged alliances and partnerships will the fight against medical fraud be achieved.
American Medial Association. 2005. ” Guidelines for pay for per- formance programs.” 06 21. Accessed 04 17, 2019. www.ama- assn.org/ama1/pub/upload/mm/368/ guidelines4pay62705.pdf .
Davis, K, C Schoen, S C Schoenbaum, and M Doty. 2007. “Mirror, mirror on the wall. An international update on the comparative perform- ance of American health care.” The Commonwealth Fund. 05 15. Accessed 04 17, 2019. www. commonwealthfund.org/Content/ Publications/Fund-Reports/2007/ May/Mirror-Mirror-on-the-Wall- An-International-Update-on-the- Comparative-Performance-of- American-Healt.aspx.
Kathleen , Catalano. 2009. “Pay-for-Performance and Recovery Audit Contractors:The Whys and Wherefores of These Programs.” Journal of Plastic Surgical Nursing 29 (3).