Who
Can Commit Healthcare Fraud and Abuse?
Acts
of fraud can be committed by practitioners, office
staff, subscribers/members and dependents, brokers, agents,
and employer groups. Anyone
who knowingly benefits from an act of insurance
fraud is equally guilty of the offense of healthcare
fraud.
Who
Can Report Healthcare Fraud and Abuse?
ANYONE
can report fraud. Referrals can be made
to the Office of the Insurance Fraud Prosecutor,
the State Disciplinary Board, or an insurance
carrier.
In
a dental practice, there are many people who
may be privy to the actual routines and habits
of an office. For example, dentists and
office staff have peers, spouses, and friends
with whom they discuss their practice. However,
the majority of our reports concerning healthcare
fraud and abuse are received from subscribers
and patients. They may report fraudulent
or questionable activities because of a disagreement
with the office, a sense of ethics, or a guilty
conscience.
In
June 2003, then New Jersey Governor McGreevey signed into
a law the Insurance Fraud Detection Rewards
Program. This law authorizes the payment
of a reward up to $25,000 to persons providing
information leading to the arrest, prosecution,
and conviction of persons or entities who have
committed health care claims fraud, insurance
fraud, or any other criminal offense relating
to an insurance transaction. The law also
creates immunity from civil or criminal liability
for any person acting in good faith by providing
such information.
Other
Ways of Detecting Fraud and Abuse
Healthcare
fraud and abuse can also be detected in a variety
of other ways. The establishment of Special
Investigations Units (SIUs) and mandated anti-fraud
training for insurance carrier employees provided
on a regular basis have made the detection of
a fraudulent claim or application easier.
Some insurance carriers regularly audit various
provider offices to verify the accuracy of claims
submitted. Delta Dental also monitors all
applications for dental insurance coverage. When
an application is reviewed, Delta Dental obtains
documentation that corroborates the applicant organization
is a functioning establishment and is in fact eligible
for coverage. The application is also reviewed
to insure it matches the terms and conditions of
the proposal.
For example, premiums are quoted for a specific
number of employees, therefore, Delta Dental will
verify the number of employees reported for accuracy.
Why do Individuals Commit Healthcare Fraud and
Abuse?
Some
of the more common excuses people give are:
- Ignorance
(I didn’t know.)
- A mistake
(Oops!)
- Passing
the buck (My accountant told me to do
this.)
- Selflessness (I
just wanted to help my needy patients.)
- Harmlessness (I
didn’t kill someone, I just made up some
extra water damage.)
- Part
of the status quo (Everyone is doing
it.)
- Getting
what is theirs (I pay a lot for premiums
and hardly ever use my plan.)
- Depersonalization (The
insurance company won’t miss a few dollars,
they can afford it, and it’s my money
anyway.)
- Apathy
(Who cares?)
- Lower
ethical standards (What’s the big
deal?)
- Easy
way to make money (The insurance company
will never find out.)
- Justification – they
only defrauded a “little”. (It
could have been a lot worse!)
- Reasonable
confusion, submitting claims is not always
simple.
|
