Who’s afraid of the big bad fraud? If you avail yourself of health care services, you should be. In a setting where professionals are trained to care, respond to and have the best intentions for your health, there always seem to be perpetrators of this harmful, expensive crime.
Health care fraud has astronomical financial and legal repercussions. When it happens, we often picture accountants and attorneys facing the charges head-on on behalf of the erring physicians. However, when someone in health care commits fraud, everyone is affected: patients, colleagues and the institution itself. Rules are set in place in every tier of the health care system. Unfortunately, different fraudulent schemes result in various scenarios where the perpetrator benefits, and the patient experiences neglect and abuse most of all.
A few get rich while many suffer
It seems everyone wants a piece of the health care pie in this trillion-dollar industry. An infographic on healthcare fraud summarizes the kind of people involved in it, as well as the common circumstances that turn them into white-collar criminals. The infographic also spotlights the “teamwork” often present in these scams. Some examples:
- Hospice and nursing homes in shady tie-ups to charge Medicaid for additional patient services
- Physicians receiving kickbacks from medical equipment suppliers in exchange for authorizing improper certifications for certain equipment
- A landlord-tenant relationship between a physician and product provider where the former receives rent while the latter benefits from referrals
- Referral-mongering doctors aiming for bribes and special benefits from suppliers
How do these scenarios affect patients? The Institute of Medicine (IOM) published a 2012 report called Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. It reveals that one-third of hospital patients undergo some form of preventable harm during their stay in the hospital. These can range from minor injuries to, in extreme cases, death. The Journal of Patient Safety also ran an article in 2013 called A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. It estimated that up to 98,000 Americans die each year from medical errors.
The alarming thing is that most of these cases are preventable.
…But nobody wants to blow the whistle.
Regrettably, many who witness these scenarios choose to turn a blind eye for different reasons. A 2005 report by the American Association of Critical-Care Nurses (AACN) called Silence Kills showed that around 60 percent of clinic staff who witnessed problematic scenarios felt “unsafe” to speak up about them. Hazardous shortcuts, misdiagnoses and poor clinical judgment are just some of the scenarios that could cause patients harm but aren’t reported in a timely manner because clinicians are afraid of confrontation — and the repercussions that go with it.
What would incentivize people in health care to actively report fraud they witness? How can the OIG protect them from backlash?
Fraud figures have been consistently high for five years
One more alarming thing in the grand scheme of health care fraud: it has become the top criminal conviction in OIG analysis charts, with as many as 993 cases in FY 2013 alone. FY 2014’s report yielded 956 cases of fraud. What makes these figures even more worrying is that they have been consistent for the past five years.
To have any form of criminal activity when health is at stake is simply unacceptable and a cause for alarm. More than ever, the health care industry needs a stricter and more reliable compliance system to help keep fraud from wreaking havoc on people’s health.