Banking Fraud - Prevention and Control

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One of the attributes of the this system that makes it so susceptible to fraud is that so many players are involved in providing services to a patient and then paying for that service. The initial players in the system are the patient and the care provider. However, it doesn't stop there. Once the patient has seen the provider the payer (patient, insurance company, government) step into the process. They are followed by the employer how may pay all or part of the patient's insurance premiums and/or pretax medical savings accounts, and vendors (for examples, drug stores, pharmaceutical companies, medical equipment vendors and manufactures). Medical frauds are complex and often include at least three of these players.

Fighting Fraud, Waste and Abuse

So what can be done? We don't need another study conducted by a government panel. We do need action. The place to start is with consumers and citizens. A comprehensive fraud prevention program to combat fraud starts with anti-fraud education for consumers and citizens. Everyone needs to know how pervasive is medical fraud and what it cost each one of us. An effective anti-fraud program begins as the grass-roots level with consistent and comprehensive attention. One story in the main-stream media every six months will never be enough. Only when citizens know what the problem is and what it costs will they being fight against the status quo.

The more technical elements of an anti-fraud program to combat health-care fraud, waste and abuse include:

• Fraud prevention programs - internal control systems within all health-care organizations to make it harder for individuals to commit fraud. Adequate review and approval processes coupled with good supervision are the keystones of an internal control system.

• Fraud deterrence programs - activities that increase the probability that fraud will be detected if it exists. The most common example of a fraud deterrence program is the conduct of frequent pro-active fraud audits. These are audits that are conducted to uncover refundee.com when there is not indication that fraud exists.

• Fraud detection programs - data mapping, mining and analysis process to detect fraud when it exists.

• Fraud investigation programs - reactive auditors and investigations conducted when there are indications that health-care fraud has been committed.

• Fraud loss recovery programs - the payer, either an insurance company or the government, must recover funds lost through medical fraud and abuse. The U.S. Code 18 U.S.C. Sec 983(c)(3) claims to right to force property forfeiture if the Government is able to establish that property was used, facilitated or was involved in the commission of a criminal offense, and that there was a substantial connection between the property and the offense.