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Health Care Fraud Feb 2011

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Submitted By skoolkid
Words 2023
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HEALTH CARE: SHOW ME THE MONEY

By defining health-care fraud, observers should be aware that hard-earned money is wasted annually. Consequently, more precautions should be enforced to safeguard citizens’ tax dollars.
Simply put, health-care fraud is the submission of false claims by individuals acting with disregard to the truth (Lovitky, 1997). Individuals, empowered to be health care providers, can be guilty of committing health care fraud, as well as major corporations (Sparrow, 1996). According to former Attorney General of the United States, Janet Reno, states health-care fraud ranks second of the top priorities of the Department of Justice, just behind narcotics interdiction (Lovitky, 1997).
Health-care fraud typically involves violations by way of: overutilization; up coding; billing for services not provided; failing to provide necessary services; and filing false cost reports (Lovitky, 1997).
Fundamentally, overutilization is defined as providing medical services not needed or required. In the process of overutilization, fraud takes place when more services are provided than what the situation calls for, or when medical services are never performed and still billed to the insurance company (Lovitky, 1997).
Up coding, according to Lovitky (1997), involves Current Procedure Terminology (CPT). The CPT code accurately describes medical, surgical, and diagnostic services and it is designed to make medical services and procedures consistent among physicians, coders, patients, medical organizations, and administrative, financial, and analytical personnel. Fraud occurs when the code assigned reflects a higher level of service than the service provided. Billing for services not provided occurs when a bill for medical service is submitted without the service ever taking place. This scheme, deliberately performed for financial gain, is known as “the

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