Eliminating Upcoding in Health Care Systems
Eliminating Upcoding in Health Care Systems
Major Categories of Health Care Fraud and Abuse
The United States Department of Health & Human Services and the Department of Justice Fraud records that approximately 3 to 15% of expenditure in health care is from fraudulent activities in health care practices across the United States. HIPAA defines fraud as the act of knowingly and willingly executing or attempting to execute schemes with the aim of obtaining a profit through deception. Fraud is also defined as the “intentional deception or misrepresentation made by a person or an entity, with the knowledge that the deception could result in some kinds of unauthorized benefits to that person or entity” (NHCAA, n.d). Abuse on the other hand is defined based on the inconsistent medical practices and can be intentional or unintentional practices that lead to overpayment of medical services to the health care provider (Joudaki, Rashidian, & Minaei-Bidgoli, 2015).
The federal Government False Claims Act (FCA) developed in 1986 aims to target health care fraud and abuse by tracking these violations and suing violators. With the help of HIPAA, the government has managed to establish Health Care Fraud and Abuse Control (HCFAC) program which is an independent legal branch that specifically aims to fight health care fraud and abuse. The fraud and abuse cases are based on the various elements in health care including health care provider fraud, a patient using insured people fraud, insurer fraud, and abuse (Joudaki et al, 2015).
