Term Paper on "Healthcare - The Truth About Fraud"

Term Paper 12 pages (3685 words) Sources: 1+

[EXCERPT] . . . .

Healthcare - the Truth About Fraud

In a quest to deeply understand the various management theories in healthcare today, this report uses an approach of first trying to understand some of the healthcare industry's concerns which in turn affect their options when applying their management theories. The article chosen was authored by Chris Farnsworth and is entitled 'The Truth About Fraud' which was in the May 1, 1997, Washington Monthly. The media today consistently puts out a message that the healthcare industry is currently trying to tackle concerns around the likes of fraud, abuse and waste. No management team in any industry will ever be able to produce an outstanding product or service if that team' management theories must first contend with these types of issues. The healthcare industry is no exception. The leaders in the healthcare community have their management theories geared first to deal with fraud and waste and secondly to move towards profitability. Fraud and waste are the types of alarms that alert the media to the many holes in an all ready pressured management process. This article review therefore focuses on one of the healthcare industry's biggest management concerns which affect the viability of any management theory.

The author through his article points out how fraud is a crime perpetrated by a large number of medical providers, employers of the insured or the insured members themselves. These crimes occur because until recently, the majority of Federal and State programs such as Medicaid were not adequately prepared to deal with fraud. Fraud in the healthcare payment system has been estimated to cost the public and the industry billions of dollars annually. Of course, there are no precise methodologies to accurately pin down a dollar amount but most authorities contend that insurance fraud is at minimum a one hundred billion dollar problem annually.

Therefore, one of the biggest concerns in the healthcare industry today is fraud and that directly affects the types of management theories that can be implemented. No healthcare management theory will be effective if there is a continued trend of rising costs within the United States healthcare system. These costs most be controlled. and, since one of the major driving factors for these rising costs has been billing and payment fraud, the healthcare industry leaders as well as governmental bureaucracies must solve the associated problems. We can consider healthcare payment fraud as any attempt by an individual or group, including whole organizations, which present some type of fraudulent claim in so as to intentionally deceive an insurer such as the Medicare or Medicaid systems as well as the various private insurers. Anytime a person or group is the beneficiary of receiving some type of unauthorized reimbursement or payment can technically be considered fraud.

As the article shows, healthcare fraud done by a medical provider could be as simple as malicious medical billing for services not provided to presenting ghost prescriptions and anything in between. The most common type of fraud by far is that of requesting reimbursement for a non-covered or non-performed service. These come in the form of billing that is actually a deliberate duplicate service. Next on the list would be performing medically unnecessary services. To many doctors are trying to obtain reimbursement by misrepresenting dates, description of service so all of these fall under the category of healthcare payment fraud. The healthcare industry leadership spends countless hours trying to implement management theories that can thwart common fraud such as incorrectly reported diagnoses to maximize reimbursement. Not surprisingly, providing false employer group membership information has become a very common fraud occurrence. The phantom patient is also a technique that medical providers use.

The Healthcare leadership does not only have external concerns. Internal fraud from employers and employees has escalated as a problem as more and more employers falsely pad their rosters in order to secure healthcare coverage discounts based on larger enrolments. Employers also have been enrolling individuals not eligible for healthcare coverage based on dates of hire or termination which also expands overall employer coverage rosters. Individual members also commit various acts of fraud including sharing benefits by using someone else's coverage or insurance card, filing false or erroneous claims for services or medications never received.

In conclusion, this article was a review of Chris Farnsworth's 'The Truth About Fraud' from the May first 1997 Washington Monthly. Even though healthcare payment fraud is punishable by both imprisonment and large fines, there are no shortages for those willing to take the associated risks. This insight provides a foundation for really understanding the various management theories in healthcare today. Healthcare management has been forced to adopt defensive options first when applying their management theories because the media continues to put out the word that the healthcare industry cannot hide its track record of trying to deal with the issues of fraud, abuse and waste. It is common knowledge that no management team's organization can create or give products or services when that organization is contending with these things. The leaders in the healthcare community will continue to implement management theories to deal with fraud and waste because those are the hot buttons for the media and public alike.

Article 2

Healthcare Delivery System

This article review focused on Healthcare Delivery Systems as a specific organizational structure in healthcare. The story covered was an Internet based article called 'Current Telehealth Applications' which was on the Telehealth Applications web page. As more and more seniors in America face the challenges of being able to afford prescription medicines, the healthcare industry has begun to lose some of its long time accepted bricks and mortar constitution. The existing healthcare delivery system for example has not been able to meet the needs of the older and poor patients in our country due to the high costs and the lack of healthcare coverage for those types of Americans. Apparently, the United States is not the only place in the world that has these obvious problems. The new healthcare delivery system of the twenty first century and beyond will be a system without walls or buildings because the economics of globalization and the convenience of the internet have begun to move into healthcare.

It is more than obvious that America's population continues to age. The baby boomers will be fully retired soon so more seniors will require medical attention based on the needs of the elderly. However, the problems of those already in the upper years will show that the existing healthcare structure will have to change in order to meet the needs of the community. Currently, a large number of our existing senior citizens are already in a position where they cannot afford the costs associated to their basic medicine prescription needs. Those seniors are beginning to move to cheaper sources for those needs as the basic rules of supply and demand kick in. For example, how many of the seniors in America have begun to look across the northern boarders of America into Canada for their prescriptions to be filled. There is obvious cost relief coming out of Canada because their Healthcare Delivery System is known for providing drugs at a much lower rates then here in the United States.

As the article pointed out, a great many medical philosophies begin in other parts of the world as each nation attempts to create a sound healthcare system. The goal of a good healthcare system seems like a universally accepted objective. One way that nation's in Europe have begun to adapt to new technology available is to utilize borderless pharmacies through innovative ideas like telehealth and telemedicine. The American seniors faxing prescriptions to Canadian pharmacies or utilizing the Internet or email to get those prescriptions abroad are using telehealth and telemedicine.

The process works by the senior faxing a prescription to a Canadian, or any nation's, pharmacy and then sends payment with a credit card or a check in the mail. The pharmacy once paid utilizes the overnight delivery industry giants such as FedEx and the medicine can be delivered the next day if need be. The internet and email have even sped up the process to become almost an instant transaction with the added benefit of a fax as secondary failsafe. Our senior's situation seems to have become a healthcare delivery system trend throughout the world. "It is striking how the issues related to integration of telehealth/telemedicine into healthcare delivery are common to many countries." (Telehealth Applications, 2004)

The United States healthcare organizational structure will indeed have to take on a new look in order to incorporate the available technology into the system. For example, new privacy laws based on the HIPAA laws will require the bulk of our nation's healthcare facilities to invest in new hardware and software technologies in order to secure the privacy of their patients as well as to communicate with the upgraded governmental Medicare and Medicaid system requirements. In the past, our healthcare delivery systems only utilized local facilities and characteristics but with our… READ MORE

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