Enforcment Against Healthcare Waste and Fraud

Healthcare Fraud

Identity theft and fraud of many types and forms are obviously a major inconvenience and hindrance to anyone that falls prey to a person that engages that crime. There are many variants and forms of fraud and identity theft out there. One of the more insidious and nasty examples of those crimes would be that which relates to healthcare. Indeed, to have people’s wallet, healthcare and the taxpayer dollar on top of that all potentially compromised in one fail swoop is a very ominous and nefarious endeavor. Even so, it happens all of the time and to all sorts of people. Regardless of the particular situation or scenario, any instances of fraud or abuse when it comes to healthcare insurance, healthcare providers and the services dispensed from all of the above are never a good thing. While healthcare is deemed to be a right to be extended without limitations to all Americans, the presence of abuse and fraud only complicates matters and prevents this from happening in some cases.


Report Structure

In a nutshell, this report will focus on the gravity and significance of healthcare fraud and abuse as an issue. This problem will be explored and summarized from a political, economic, social and ethical perspective. The specific populations involved run the gamut from individuals to families to communities, cities and to the healthcare system itself. There will be a reflection on what all is going on and what can be said about it and there will also be a listing of gaps that apparently exist when it comes to the literature. A conclusion and recap of the findings will be part of the body of work in this report as well.


Before getting to the particular findings and analysis related to this problem, it would be wise to recap the situation and the challenge at a high level. The abuse and misuse of the federal and ancillary healthcare systems in the United States has reached a level that has made it a top priority when it comes being addressed by the federal government. While general inefficiencies and the veritable hodgepodge of systems and frameworks that make up the healthcare system are bad enough, there are those that unapologetically and/or illegally breach and exploit these inefficiencies and problems. The government investigations and inquiries that have resulted from both of the above has led to a lot of disdain and dissatisfaction on the part of providers and such as being investigated on its own, even if there is no merit to the idea that a provider is part of the abuse, can be stigmatizing and can absolutely kill productivity and a firm’s reputation. Healthcare administrators in particular are often behind the proverbial eight ball in that they have to seek ways to reduce the chance that his or her employer will become the target of a fraud investigation due to red flags being tripped or an accusation being made by a person or agency that the administrator’s employer has contact or interaction with. Given that, administrators have to put themselves out there and assert that the documentation and coding done by the firm is complete, that it is accurate and that it is done in an ethical and legal way. The documentation, digital or paper, must support what did or did not happen for each patient that comes through the front door. Indeed, the claims reimbursement process hinges on honesty and completeness and when it comes to a healthcare practice, the administrator and his/her subordinates are responsible for making sure things happen properly and correctly (Budetti, 2015).

In addition to the above, there is an absolute duality when it comes to the healthcare paradigm, especially when it comes to for-profit offices and collectives. Indeed, there is the patient care side of things and the corporate/administration side of things. Both sides to the practice have their own list of rules and bylaws that must be followed to the letter. It is often perceived and not actual, but many hold that there is a conflicting mindset and duty when it comes to the two sides of a practice and what goes into its operations. Indeed, a for-profit business is all about making money but medical care is about care quality, attaining the best outcome and so forth irrespective of the money that has to be spent to get to that end. To be sure, this does not mean that waste and over-diagnosing should be done. At the same time, treating patients like regular customers and not people with valid concerns about their life and livelihood is less than wise. Making medical decisions about things that are not aesthetic and voluntary in nature based on money is also an ethical landmine because the idea is that healthcare should be about doing what is best for the patient rather than the money that has to be spent when it comes to the same (Budetti, 2015).

Given this paradigm, it is exceedingly prescient and wise for there to be corporate compliance programs at clinical practices that weigh and balance these sometimes opposing ideals and concerns in a way that is efficient, ethical and legal all at the same time. Effective strategies can and should be drawn up that ensure that all relevant regulations and ethical standards are complied with while also minimizing the chance of fraud or risk when it comes to healthcare administration. For example, there should be a coding compliance program and it should serve as a linchpin for any wider corporate program for medical practice. Further, there should be a risk assessment so as to identify risks, what impact they could have and what should be done when those risks are manifested and identified. It takes administrators that are proactive and creative so as to allow for the convening and execution of a multi-disciplinary team of professionals, both medical and administrative, that get things done and do them in the right way. This team of professionals can and should make it a point to address the compliance plan for the firm and they should cooperate with each other when it comes to perfecting the policies and procedures that the firm will use so as to stay within the ethical and legal boundaries that exist (Budetti, 2015).

Economic Issues

When it comes to the economic facets of what fraud and abuse end up causing, these are not hard to figure out or consider. Indeed, economic issues are all about how much services cost, whether patients have the ability to pay for services, where those payments come from and so forth. When there is rampant fraud and abuse, there are a number of effects that have vast economic implications and consequences. Just as one example, the economic expenses and results from fraud and abuse find a way back to impacting the innocent practices and clients in one way or another. For example, if a person files a specious malpractice suit or even just incurs legal costs for a provider to begin with, verdict or not, this causes malpractice insurance to be more expensive and this leads to higher overhead for a provider. Beyond that, it is often cheaper and less aggravating for a doctor to just settle as having a prolonged legal battle and/or a questionable verdict that could total in the millions is deemed to be not worth the problems that are dealt with. When it comes to claims and such that are clearly fraudulent or when it comes to people that use services in a name other than their own, this would generally lead to unpaid claims. This would impact the economics of someone if their identity were stolen and this too would drive up the overhead and unrecoverable costs that a medical firm would endure. While there are limitations and roadblocks put in place to prevent patients from paying too much, this can generally be gotten around in the form of what is charged to non-insured patients, whether an office will financially penalize a person who misses an appointment (and to what degree) and so forth. There are enough economic problems due to the overhead and aggregate costs going higher and higher. People are skipping doctor appointments and putting off treatment when they absolutely should not be doing so and this is a huge part of why minorities are the hardest hit when it comes to these things given that they tend to be among the poor and disadvantaged. Regardless, the economic impacts of fraud and abuse impact everyone. In some limited cases, the fraud and abuse comes from the patient himself/herself. Indeed, a common cold should not generally require a doctor’s visit and it certainly should not involve a trip to the emergency room. That is an issue but people that are outright lying to gain money or free treatment are obviously the bigger problems. Healthcare should be there for those that reasonably need it…no more and certainly no less (Golinkin, 2013).

Political Issues

As for the political aspects of this problem, that is even more complicated. A huge political football that gets tossed around at times is that the federal government has to ration services to some degree given that there is a finite amount of resources available. While this may seem more like an economic issue, it is much more political than economic. Beyond that, there are those that say that the government should have little influence in healthcare because it deemed to just make the bureaucracy bigger and the quality of care just goes down. The struggles of the Patient Protection and Affordable Care Act, often referred to as Obamacare, and the problems with the Veteran Affairs hospitals and clinics are just one example. Proponents of these public and government-run infrastructures assert that the for-profit and private care model is broken and dysfunctional. However, there are others that say that it would be easier to just skip the PPACA and just buy insurance policies with private healthcare insurers rather than adding to the committed budget dollars each year. The point to be found with political groups and behaviors is that every major stakeholder and party has a dog in this proverbial political fight. However, some voices are more represented than others and it is the individuals struggling to survive and afford their daily lives that get ignored but still hit the hardest (Joshi, 2015).

In short, politics has become all about acrimony between the two parties and who has the bigger dogs and sums of money in the political fight. This really does need to change as the needs of those that are most vulnerable are not being met. When it comes to fraud and abuse, there is a lot of tough talk from politicians but not nearly enough action as it all seems to be about soundbites and bravado rather than getting something done. However, that is not entirely fair as Medicare and Medicaid (not to mention Social Security Disability) reject claims every day that seem suspicious. At the same time, there is a lot of talk that people that are absolutely entitled to benefits are being maligned and punished due to the provable misdeeds of other people that are clearly lying or at least telling half-truths when it comes to their claims. Indeed, there are many people on Social Security Disability (SSD) that truly need it but there are others that use it as a backup to unemployment insurance and/or they will stay on SSD even if they could return to work or find a job that meshes with their current physical ability. Be it no surprise that Medicare, Medicaid and SSD are all facing budgetary problems and people that are milking and abusing the system are just part of the problem, not to mention people that are outright lying to get benefits that they are not entitled to. It is clear that these three programs are needed but the politicians need to be the adults in the room and they need to create a system that gets and sustains benefits for those that need them and denies (or even prosecutes) those that do the wrong thing and try to get benefits that are not called for or level (Joshi, 2015).

Efforts have been made to do precisely this but two patterns emerge no matter what is done. One pattern is that people will say that enforcement is being done too much or too harshly. They say that people that do need the benefits (or should be entitled under the law even if the current rules say they are not) are not getting what they should. On the other side, there is the argument that some (but not all) people are gaming and abuwsing the system and this is ruining it for everyone else. One example would be the clause in the PPACA that says that insurers may not deny or delay coverage if someone has a pre-existing condition. That sounds good on paper but there are some (again, not all) people that actively exploit that. They are happy to pay the rather nominal fine and just worry about insurance when they get sick or suffer a catastrophic injury. An example would be someone that could afford insurance but does not buy it. That same person could then contract Type II diabetes or something else that requires a lot of money being spent on healthcare. That person could then buy a policy right away and get benefits right away despite the fact that they are just now paying into the system and their contributions to the “pot of money” were nil a mere week ago. In essence, the system is allowing free riders and fraudsters to abuse the system. The enforcement mechanisms and rules need to be adjusted in such a way to discourage this such as harsher penalties for fraud or better rules for new patients when it comes to pre-existing conditions, especially when affording insurance is not the issue (Joshi, 2015).

Social Issues

As far as social issues go, this very much dovetails and meshes with the political and economic paradigms mentioned above. To be sure, the economic and political traits and circumstances in play at any given time in the United States are going to have an effect on the social ramifications that render as a result. As noted above, healthcare is seen as a right and a must for many people even though the United States Constitution does not say as much, unless one implies this from “life and liberty” or something else along those lines. Even so, healthcare is something that many people are social and passionate about. Society, of course, is what drives who is elected, how those politicians are perceived and what is desired by the people. Beyond that, society might not have a rational or reasonable view of the medical field or industry and thus their feelings on the matter might not be complete and focused. For example, people talk about the fact that healthcare should be “free.” Even if there is no cost at the point of proverbial sale when it comes to healthcare, someone is paying for it. If the person receiving the care is not paying for it, then that means that it is being reimbursed from the government (which comes from taxpayer dollars), a healthcare insurance company (which is paid for by customer premiums) or the office giving the care is “eating” it (Badano, 2016).

Ethical Issues

When it comes to fraud, abuse and misuse, one might think that ethical issues might be the easier of the paradigms mentioned throughout this report to codify and describe. However, this is simply not the case. Just to give a few examples, the fact that healthcare is a for-profit venture a lot of the time is offensive to some people. Second, some people have no hesitancy when it comes to defrauding the government even though taxpayer dollars are in play. Third, where people draw the proverbial lines when it comes to ethics can differ greatly depending on who is drawing the line. Indeed, there are those that say that the government should only regulate, not run, any healthcare venture. Others say that there should be universal care and private healthcare should not control anything. Regardless, both systems are used, abused and exploited whether they exist in concert or on their own. The hard part when it comes to ethics is that many of the ethical boundaries are drawn by people that are elected and appointment and this often comes down to majority rule. While majority rule is often on the right side of history, the law and what would typify medical ethics, this is not always true. Beyond that, there is a sharp demarcation between the groups of people about how the system should be structure. However, everyone tends to agree that abuse, fraud and misuse of the healthcare system is a bad thing. The challenge is to draw up the rules and just how aggressive one will be when it comes to enforcing it. For example, many hold that the aforementioned free riders should simply pay a fee or fine that is approximately what insurance would cost. Others say that the fine should “hurt” a lot more because everyone needs to be in the system. Indeed, if a fine is paid to the government rather than to Blue Cross and someone exploits the no wait period for pre-existing conditions with the latter, it is Blue Cross that is getting hosed…not the government (Nordtug, 2015)


There is a challenge when it comes to assessing people and populations. While the individual details and outcomes for a singular patient matters greatly to them, legislation and enforcement against abuse and fraud is very much based on the macro level. Indeed, the government has to craft legislation and regulations that bring a good outcome to the most people possible. Even with those best efforts, there are people that will be outliers and exceptions and they will suffer or greatly benefit because of this. In short, there is more scrutiny towards the healthcare system as a whole and the entire communities involved rather than the families and individuals at the lowest levels of analysis. This is not to say that individual outcomes are irrelevant because that is not true. However, giving the best benefit to the most people means finding patterns of people that are not getting results and addressing that problem at its source. Conversely, addressing fraud and abuse is about finding similar patterns that show something amiss is going on. Any people or companies that meet the associated red flags should be given the microscope treatment, so to speak. Indeed, some of those people are completely innocent. Much like an IRS tax audit, a red flag does not mean malfeasance is occurring. However, it could be and it needs to be looked at to ensure that something important is not being missed or glossed over (Han, Park & Kim, 2016).


Regardless, the stated ethical and legal boundaries that exist should be the guideline for any enforcement. If those guidelines are wrong, it is up to legislators to fix that. The problem is that so many people are engaging in demagoguery, character assassination and so forth. There are other countries like New Zealand that have superior systems without high taxation. Indeed, New Zealand’s tax and healthcare system are both much simpler yet they have better outcomes than the United States across the board when it comes to staff to patient ratio, life expectancy and so forth. In short, the United States needs to go back to the drawing board and stop using healthcare and tax policy as a weapon or something to be negotiated about. Of course, part of that will be properly dealing with offices or patients that cannot or will not abide by the rules and ethics that pervade the United States healthcare system. The existing system and framework works fine for many people but there are so many people that fall through the cracks due to one reason or the other. These are the same people that are most affected when healthcare firms suffer financially or even go out of business due to the misdeeds or abuses of either patients or other offices.


When it comes to people, families and gaps in the literature, there is only so much that can be done at the macro level. People need to realize that they are very much on their own or that they at least need to be careful and mindful of what they do. Many to most gaps in the literature are going to be borne of the complexity and sheer size of the proverbial playing field. For that reason alone, making broad-based assumptions or addressing issues at the macro level is going to lead to misfires and mistakes. However, doing nothing is a non-starter.


Badano, G. (2016). Still Special, Despite Everything: A Liberal Defense of the Value of Healthcare in the Face of the Social Determinants of Health. Social Theory &

Practice, 42(1), 183.

Budetti, P. P. (2015). New strategy, technology emerging in ongoing fight against healthcare

fraud. Modern Healthcare, 45(29), 25.

Golinkin II, J. W. (2013). Fishing with Landmines: Healthcare Fraud and the Civil False Claims

Act — Where We Are, How We Got Here, and the Case for More Trials. American Journal

Of Criminal Law, 40(3), 301-326.

Han, K., Park, E., & Kim, S. J. (2016). Unmet healthcare needs and community health center

utilization among the low-income population based on a nationwide community health

survey. Health Policy, 120(6), 630-637. doi:10.1016/j.healthpol.2016.04.004

Joshi, N. K. (2015). Party Politics, Governors, and Healthcare Expenditures. Economics &

Politics, 27(1), 53-77. doi:10.1111/ecpo.12050

Nordtug, B. (2015). Levinas’s ethics as a basis of healthcare – challenges and dilemmas. Nursing

Philosophy, 16(1), 51-63. doi:10.1111/nup.12072

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