The Health Impact of Fraud

December 21, 2018

As the PI Director at an MCO and as the VP at the South-Central US ZPIC, I saw the impact that fraud has on the bottom line every day.  Healthcare fraud costs the government and private insurance billions of dollars annually.  The system is built on trust, as consumers/patients, we trust that the physician, hospital, or clinic submits a bill that accurately reflects the services received.

However, when unscrupulous providers submit claims for more complex procedures than performed or for services not rendered, it creates a claim for the service.  And this directly affects the health record and future health care possibilities for the beneficiary.

In the case of an Illinois physician who billed $1 million to Medicare and Illinois BCBS between 2008 and 2013, the physician created detailed false records for each patient for the services (that were not provided) – in the event the claims were audited.  Most of the patients were unaware of the claims.  If the patient applied for life insurance and the information was requested by the physician as part of the assessment, it would increase their premium or worse, denial of coverage.  Additionally, if the patient did have a condition arise that warranted a specific service, if there were records of the procedure having been performed, the service would be denied.  Moreover, a physician conducting the evaluation may prescribe inappropriate and potentially dangerous treatment based on the information in the medical records.

The rising cost of healthcare concerns every patient.  But there can be even more severe and complicated consequences for the patients if the fraud creates inaccurate medical history….