People can be affected by healthcare fraud and abuse directly and indirectly. Fraud is defined as an intentional deception, false statement or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. Abuse is defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices. Intent is the key distinction between Fraud and Abuse. An allegation of waste and abuse can escalate into a fraud investigation if a pattern of intent is determined (B, Tom). Both, fraud and abuse can be committed by physicians, patients, and private insurers. Situations of fraud and abuse that occur in our healthcare system are billing for services that have not been provided, over-billing for services provided, and misdiagnosing health conditions in order to avoid financial responsibility for the proper treatment of illnesses. .
Define the Problem .
What can decrease the high costs of premiums and co payments? With the decrease of fraud and abuse, premiums and co payments would not be high. Who pays for fraud and abuse healthcare bill? Medicaid and Medicare are the two federal programs that are funded by taxpayers who pick up the fraud and abuse bill. It is projected that fraud and abuse account for between 3 to 15 percent of annual expenditures for healthcare in the United States (Eberhart III, Hart-Hester, Pierce, & Rudman, 2009). These massive expenses are avoidable and obstruct the ability to provide universal healthcare services that are affordable and proficient. Physicians commit fraud and abuse insurers and subsidized federal programs in order to force up the cost of services. When it comes to patients, patients commit fraud and abuse insurers and subsidized federal programs to obtain preventable services, payments, and medical procedures.
