Private insurers play their role in fraud and abuse by subsidizing federal programs in order to dishonor medical claims and keep away from financial responsibility for essential medical services. Increased costs of fraud and abuse results in increased insurance premiums, taxes, and costs for medical treatment. .
Literature Review .
Fraud and abuse in our healthcare system indicates a priority of wealth over health, puts patients at risk, and hinders our national interest of quality care. Medicaid and Medicare are especially vulnerable to fraud because eligible individuals may never see their bill for services; it goes directly to a fiscal intermediary (for Medicare) or a designated payer (for Medicaid), (Barton, 2007). In a report made by Jessica Zigmond, Aghaegbuna "Ike" Odelugo speculated on how and why the fraud occurs, "This is a nonviolent crime and is often committed by very educated people, including businesspeople, hospitals, doctors and administrators. It reaches across all ethnic and racial lines." He added that healthcare fraud often preys on what he called an unsuspecting victim base of Medicare recipients: elderly citizens looking for care and attention. The Priority Health Fraud & Abuse department is targeting specific practices in an effort to recover funds and end fraudulent practices. Among these are identifying claims which have been incorrectly unbundled, tracking claims for controlled substances to discover abuse and auditing claims to identify duplicate claims and coding errors (Vorel, 2011). .
Despite federal legislation and a commitment of millions of dollars to fight fraud and abuse, research suggests that less than 5 percent of the losses from fraud and abuse are recovered annually (Eberhart III, Hart-Hester, Pierce, & Rudman, 2009).
