The healthcare industry is one of the largest industries in the United States, generating hundreds of billions of dollars in revenue each year. Equally as big is the intricate and extensive network of primary care providers, nurses, and specialists, not to mention the entities of the pharmaceutical industry. With so many people, so much money, and in many cases, so little regulation in place, fraud and dishonesty are bound to occur.
Claim Fraud and Unnecessary Procedures
Many times, providers make honest mistakes at the time of filing a claim. But millions of dollars a year are lost due to claim fraud on the part of providers. Some providers will render unnecessary services to get more money from patients and their insurance companies. When patients visit their primary care providers for a routine check-up, all too often their visit turns into a maze of confusing tests and diagnoses. This sometimes will lead to a referral to a specialist, in turn costing either the patient or insurance company more money than needed. The providers that engage in this type of activity use their extensive knowledge and medical jargon to confuse or convince patients that further work is needed, when many times a procedure can be avoided altogether.
Unfortunately, claim fraud and unnecessary medical procedures are a part of every major healthcare branch. How can you tell if you’ve been a victim of this? Because most people trust their healthcare providers and are not medical experts, it can be hard to tell when something is medically necessary.
One suggestion is to seek a second opinion from another provider. If it is truly a matter of life and death, a patient generally will realize this before a routine visit to their provider. Another way to recognize that the provider is trying to pile up procedures is to look at the relevance of a procedure or referral. If the provider is venturing into hazy territory, they are usually beginning to employ medical jargon to confuse the patient, thus convincing them that they are correct. An honest provider will make sure that the patient understands what is being done and why.
Kickbacks are another dishonest measure in the healthcare industry related to unnecessary referrals. Sometimes, providers will work together to get new patients via referrals. An example of this would be a general dentist referring a perfectly healthy patient to an endodontist. The two or more providers usually set a system of sorts, stating that if a certain provider refers a patient to another, the first one will pay the second a commission. This is yet another practice that is slowly corrupting the healthcare industry and is hard to monitor or regulate.
While there aren’t any exact figures of how many kickbacks occur each year, the FBI estimates that healthcare fraud via kickbacks is about $80 billion yearly. In today’s economy where every dollar counts, healthcare fraud is poisoning the very industry that is dedicated to wellness. You can do your part by staying educated about your current health status and always to getting a second opinion about any major procedure or diagnosis. Providers can only get away with what patients and society allows them to. Education and diligence are the key to keeping the healthcare an industry of wellness and not personal gain.