For years significant resources have reportedly been directed towards combating health care fraud by insurers, regulators, law enforcers and legislators. Yet, despite these reported efforts, it would appear, based on the annual estimates, the problem continues to grow and flourish.

Could this indicate that health care fraud is at epidemic proportions and can’t be stopped as our health care system is infested with health care providers who will stop at nothing to make a buck? I think not.

My experience, over two decades of working with insurers, law enforcers, regulators and health care providers, suggests that most health care providers are honest, ethical and strive to do the right thing!

Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our health care fraud problem is caused by a number of factors, including:

1. Inadequate education for health care providers relative to coding and payer standards.

2. Deviant providers.

3. Inadequate training for claims handlers and claims investigators on coding and provider standards.

4. Inept claims handling and claims investigations by insurers prior to paying claims.

5. Lack of communication from insurer to provider on what is required.

6. Paucity of reliable training for law enforcers regarding the investigation of health care fraud – from identification to prosecution.

7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.

8. Lack of interest or commitment by prosecutors – big cases big problems, little cases little problems.

9. Lack of accountability for all segments of the health care delivery system – provider, payer, regulator and enforcer.

Insurers, the main reporter and victim of the fraud, indicate that all policyholders pay for the fraud in the form of higher premiums. According to the National Insurance Crime Bureau, the average American household will pay $200 more every year in premiums to pay for the fraud.

Insurers are very aggressive in reporting how costly the problem is, revealing estimates of double-digit percentages of claims submitted that are fraudulent, and billions of dollars lost each year due to fraud. These reports and estimates weigh heavily in the minds of state insurance regulators when they allow insurers to raise premiums.

Basically, what insurers and others refer to when they reveal their estimates on the frequency and costs of health care provider fraud is the billing for services not rendered, billing for services that are substandard and/or unnecessary, billing for services that misrepresent the nature of the service provided, billing for services that misrepresent the actual service provider…

The sweeping nature of the attention health care providers are getting, even those not engaged in fraudulent activity, by insurers in post-payment audits is unprecedented, and may take away from the ability of our health care providers to do what they do best – make people better! It is unfortunate that today, health care providers may spend more time documenting and defending their services to a multitude of sources, to include insurers, regulators and law enforcers, then they do providing health care services to patients.

Health care fraud is a crime that should be dealt with swiftly, responsibly and severely! But, health care fraud should not be used as a vehicle for one to prosper at another’s expense. Insurers are in the business of making money, and they are doing just that, making money – making a lot of money! This money comes from premiums collected on the sale of policies to consumers seeking protection from future (unknown) losses.

Many insurers are in a position to limit their potential health care claims exposure as they possess the ability to tell insureds’ what doctor they can see, what treatment services they can get, and how much will be paid for the services.

Further, insurers may capriciously limit payment on health care claims denying health care services reported by health care providers, asserting the services were illegitimate, claiming the services were fraudulent. Many insurers conduct claims-evaluations, reportedly for the purpose of determining if the health care services rendered by the provider were usual, customary and/or reasonable (UCR). Consider that by definition, “fraud is the knowing and willful deception or misrepresentation of the facts with intent to receive an unauthorized payment.”

Wouldn’t such an evaluation be considered a fraud evaluation? It is purportedly done for the purpose of determining if the health care provider misrepresented the nature of the services provided and reported, i.e. fraud.

Unfortunately, the UCR evaluation seems to have little to do with actual fraud fighting, but everything to do with cost containment and the bottom line for insurers. These evaluations typically do not identify that the health care provider did not provide the reported services, but instead report subjective opinions of consultant providers who usually do not even see the patient. In many cases, insurers may successfully reduce the health care provider’s billings using UCR evaluations – not because the evaluations were accurate, but because the health care provider did not have the knowledge or necessary resources to fight back.

The effectiveness of these evaluations as a means to combat fraud is questionable, and may be non-existent.

Check with your state insurance regulators and health care boards to determine if insurers refer their UCR evaluations to them for fraud investigations, and, if so, ask them how many. Ask your local law enforcers how many cases they investigate or prosecute that were based on UCR evaluations.

Further, ask your insurer what percentages of their estimated losses due to health care fraud include UCR evaluations. And, ask your insurer why, with their duty and ability to examine all claims, are they unable to do a better job in not paying fraudulent claims.

Interestingly, since the late 1980’s, health care providers have had a standard coding system. This system, known as Current Procedural Terminology (CPT), is used by providers to report and bill for health care services rendered to patients.

CPT was promulgated by the American Medical Association (AMA) so that all health care providers, regardless of discipline, could accurately report their services and be compensated for services rendered.

Although CPT has been around for decades, there are no standards of education and training required of health care providers for the proper use of the codes, or insurers for what the codes mean. This may lead to a systematic problem in our health care system, as an unnecessary adversarial system is created between our health care providers and health care payers based on an ‘attack and defense’ of billing codes and treatment records.

Both are looking at the codes, viz., one for the purpose of reporting services to seek compensation, and the other for determining what they will pay.

It should be evident, from the annual reports, if they are accurate, that our health care fraud problem will not be solved solely by amassing a large amount of resources to attack the problem, creating consortiums to share information and research the problem, or with the introduction of additional laws or regulations from politicians stumping for re-election. The investigation of health care fraud for the purpose of prosecuting the offenders is needed. But, also needed is a mandatory educational process for our providers, insurers and investigators on combating health care fraud.

The health care fraud problem is too complex to be battled by the few. Health care fraud is a problem that demands a greater participation by the principals of our health care system, so as to increase the likelihood that our successes in combating this costly problem will be enhanced, identifiable and verifiable.

Health care fraud is a problem – just read the news, but it is a problem that can and must be successfully addressed. This will only happen once our fraud-fighting team is completely accountable and includes the active participation of health care providers.

There is no stronger voice against health care fraud then that of honest and ethical health care providers – who, by the way are also insurance and health care consumers and part of the premium paying public. Most health care providers do not engage in fraud and would like to see those who do be stopped and put out of business. However, the current fraud fighting arena has health care providers – even the honest and law-abiding ones, pitted against insurers and others.

Health care providers who are not engaged in fraudulent activity must endure aggressive and invasive encounters with insurers to get paid for legitimate services provided. This process has a counterproductive effect on our overall success in combating health care fraud.

Health care providers who are not engaged in fraudulent activity may possess information and knowledge that would be useful in assisting health care fraud fighters. These providers could potentially assist at the street-level on the identification of health care providers engaged in fraud.

Furthermore, health care providers who are not engaged in fraudulent activity may assist fraud fighters with establishing the evidence to support prosecutions of the fraud. However, with the current adversarial system, health care providers who are not engaged in fraudulent activity may have neither the opportunity nor desire to assist fraud fighters as they are fighting payers for their mere financial existence.

Maybe it is time the various health care disciplines and health care provider associations formed an alliance to be the provider’s action arm to work closely with law enforcers in attacking insurance and health care fraud, just as the insurance industry purports to do. And, just maybe, with such an alliance, we would actually see a drop in the annual estimates of the costs attributed to health care fraud – currently they range, depending on the source, from $20 to $160 Billion.

Health Care Delivery System is one of the most important systems that should be handled with professionalism and by serious manner. Health is only one of the basic right of every individual in which he or she is privileged to experience it in a higher or efficient level. It is known for a fact that some third world countries are lacking of efficient health care delivery system resulting to low performance level of delivering health services to masses. According to Ducket (2004), he proposed that the goal of health care system is divided in two dimensional approaches to evaluate it. This includes quality, efficiency and acceptability on one dimension and equity on another. The two dimensional approaches are intrapersonal approach and the other is interpersonal approach. Intrapersonal approach includes the health care service that is being delivered using ourselves as a start of communication. It is also referred as thinking. Thinking of such ways or plans on how to achieve effective communication in our own ways or strategies to build bridges meanwhile, interpersonal approach is an approach that includes relationships or communication between people. This means that in heath care delivery system, for it to be efficient, one should approach in the sense that he or she will become a channel or medium to bridge gaps between people and health care delivery system providers. Nowadays, health care delivery faces continuous or constant change in terms of its different field or aspect. It is one thing that is subjected to change for the purpose of giving or lending appropriate and efficient services to clients or patients that need it. Facilities and human resources are now very sophisticated in terms of lending health care services.

In Colorado, no matter what type of health insurance plan you have by law you have certain rights. These include coverage for certain mandated benefits, the right to know what your plan covers and what it does not, and the right to appeal all insurance company decisions when it comes to denying your claim. If you are denied, the reasons have to be in writing.

If you have a managed care plan -health maintenance organization (HMO) or preferred provider organization (PPO) plan, you are required to go to certain doctors and hospitals, and all requests must be reviewed. You have to be covered for emergency services even if the services fall outside of your health plan. And, if you need specialized services, you have the right to be referred to a specialist.

If you are a small employer, no employee can be denied health benefits because of a medical condition, and your policy cannot be cancelled unless you fail to pay the premiums. Your rates cannot be raised if your medical expenses are high, and you can by coverage through one of Colorado’s health care coverage cooperatives. This allows you to select plans for a variety of insurers. A group health plan might have a 6-month waiting period for pre-existing conditions, but pregnancy is not considered pre-existing and must be covered.

If you are not insured at work and can’t get individual health coverage because you’ve been turned, you may be eligible for CoverColorado, a subsidized state program for uninsurable individuals. Because of risk factors, CoverColorado premiums are about 30 percent more.

Colorado has several programs for those who cannot afford private health insurance. They include Medicaid, Child Health Plan Plus and Colorado Indigent Care — a state program that provides partial reimbursement to providers for some of the care.

The Canadian Health Care System is based on several socialized health insurance plans providing full coverage to Canadian citizens and a model to follow that the American Health Care System has been analyzing for a while.

In Canada, federal government set the guidelines that apply to the different provinces and territories of the country in health matters, but the system comes from public funding on a territorial or provincial basis.

Because every Canadian region manages its own health care system, there is too much controversy and debate in relation to health care coverage for both locals and people visiting the country.

People who want to access the Canadian Health Care system must apply for a provincial health card and wait for no longer, than three months to obtain their health card in the case of new immigrants.

While the Canada Health Act guarantees that all residents of a territory or province will be accepted for health coverage, temporary visitors can only access this system purchasing insurance by themselves.

However, there are also Public Health Care Providers that ruled under the same act, providing services such as hospitals, dental surgery, ambulatory services, primary care doctors, and specialists to cover provincial insurance policies.

As a visitor to Canada, you can purchase a health care insurance policy and benefit from these public services during your stay in the Canadian territory.

Canada counts with about 30,000 primary care doctors, who account for over half of all Canadian doctors so you will not have a problem finding a physician that can provide you with preventative care or basic medical treatment.

Specialist doctors account for 28,000 all over the country and there are countless private clinics operating in the country offering specialized medical services, although under federal law they should not provide those services covered by the Canada Health Act.

Even though, most clinics offer such services regardless the legal limitation, they are covered by private insurance policies to provide health care assistance to people that otherwise would be left without medical protection.

Private insurance in Canada may cover up to 80% of medical cost and it is available to visitors and local residents unsatisfied with their provincial or territorial health care system.

In terms of medical availability as of 2007, there is one primary care doctor for every 1000 Canadians, who spend nearly $3,300 per capita on health care attention every year.

Keep in mind that the Canadian Health Care System does not provide basic services to residents, and some of them are those that visitors usually require, such as optometrists, dental services, and prescription medication, which people have to pay.

There are lots of different kinds of health insurance. Plan that cover medical services and prescription medicines, plans that cover dental expenses, disability insurance that replaces income lost due to extended illness or injury, long-term care, and so on. In the United States, people typically refer to the plans that cover medical expenses as “health insurance”, and these plans are usually bought by employers and offered to employees as part of their compensation, or “benefits”.

Health insurance plans are usually sold once, then renewed on an annual basis. So when a consumer buys health insurance (either directly or through an employer), the insurer agrees to pay for health expenses as long as the premiums are paid on time and the account is in good standing.

Health insurance plans come in two flavors: “Fee-for-Service” or “Managed Care”. Both types of insurance cover major medical, surgical and hospital expenses, and are often referred to as “major medical plans”. Fee-for-service plans pay the medical service provider a fee for each service provided to a patient, and that patient can usually go see whatever health care provider they wish. Managed care plans, on the other hand, pre-pay contracted providers for each member’s coverage in advance. Members are offered a financial incentive to use providers who belong to the plan.

Here are a few common terms that you’ll probably run into:

Deductible: This is the amount you must pay out-of-pocket before the insurer will pay anything. Deductibles can vary widely, ranging from $0 to a few thousand dollars.

Co-insurance amount: This is the percentage of your medical expenses you must pay after you reach your deductible. This will typically range from 10-30%.

Maximum out-of-pocket amount: This is maximum amount you are required to pay in a given year, after which the insurer will pay 100% of the cost of covered medical expenses.

Covered benefits: Types of medical services the insurer will pay for.

Exclusions: Types of medical services the insurer will not pay for.

Its true: there’s a lot of jargon, and plans are difficult to evaluate and compare. But it’s important, and worth your time. Carefully review plan descriptions, and take your time to understand the coverage of any plan you’re currently under – or considering purchasing.

President Obama signed into law comprehensive healthcare reform legislation that contains a program known as the Community Living Assistance Services and Supporters Act (CLASS Act).

The passage of CLASS does not negate the need for private long-term care coverage in any way. Many of the details regarding the CLASS program are not yet defined and will be developed through Government regulation. The following is designed to address what is known currently and to answer the most common questions being asked.

What are the general provisions of the CLASS Act?

The most of the important details for the CLASS program have not (yet) been defined. They will be developed by the Department of Health and Human Services over the next few years.

But, simply stated, CLASS creates a new voluntary government program under which participants will pay a monthly premium and will be eligible for modest benefits for their long-term care needs after five years of paying premiums.

While CLASS is often characterized as a long-term care program, it is primarily designed as a program to provide future assistance to the working disabled. Traditional long-term care insurance requires that applicants meet certain good-health requirements. CLASS will not have such health qualification requirements. The plan will be available on a guaranteed-issue basis.

When will the CLASS Act begin?

While provisions of the CLASS Act become effective in 2011, there are so many details to be worked out that most experts don’t expect the plan will become available until 2013.

For example, not only do costs have to be determined but employers must be given sufficient time to educate employees and prepare to start withholding premiums from employee paychecks.

Following implementation and withholding of the first payments from employees’ paychecks, there is a five-year waiting period during which premiums must be paid before the participant becomes eligible to receive benefits. As a result, the earliest anyone could be receiving CLASS benefits may be as late as 2018.

Who will pay?

CLASS is intended to be a voluntary plan primarily offered by employers and paid for by employees. Or simply stated, money will be withheld from paychecks — similar to the way Social Security (FICA) payments are withheld from paychecks.

There are provisions to make the offering available to others who may be self-employed or who may not have access to the plan through an employer.

Congress made CLASS an “opt out” plan. This is an important point that people need to be aware of. Unlike Social Security or Medicare that are mandatory, CLASS is a “voluntary, opt-out” plan. If that sounds confusing, it is. Read the question below regarding “opt out”.

What will the insurance coverage cost?

The monthly premium that will be charged by the government and deducted from paychecks has yet to be determined. There have been a wide range of estimates – and we will not speculate on the final cost.

Congress required that the CLASS plan should be fiscally sound for a 75-year period. Simply stated, the goal was to have the amounts paid by participants ultimately be sufficient to pay future benefits without the need for taxpayer support.

Because of the “guaranteed (health) issue” nature of the CLASS plan, many experts explain that those most likely to apply for CLASS policies will be those in poorer health. This will likely create more people requiring benefits in future years. A fiscally sound plan will mean initial premiums could be high (as much as $1,500 to $2,500 a year per-person. Some say they could be higher. But we’ll have to wait for the Department of Health and Human Services (HHS) to set the rates people will pay.

Premiums can be increased yearly to ensure that the CLASS fund is actuarially sound.

Remember that CLASS is not a contractual obligation. Future provisions (from costs to benefit eligibility) can be changed. And, of course, while the intent of the law is to avoid taxpayer funds, CLASS could inevitably find itself underfunded the way Social Security and Medicare currently find themselves.

Explain the five-year waiting period before benefits begin.

Once enrolled, participants must pay premiums for five years, after which they will be eligible to receive certain benefits for their long-term support and service needs. They must also have worked for at least three of those five years.

What coverage or benefits will be provided?

While the exact benefits to be provided under the CLASS program are yet to be determined, here is some general information.

Remember that to be eligible for benefits, you must pay premiums for five years to be eligible to receive certain benefits for long-term support and service needs. The participant must have a functional impairment expected to last more than 90 days and which requires substantial assistance with two or three Activities of Daily Living, or has substantial cognitive impairment.

The health insurance card system was introduced and implemented on a national scare in 1999. This system issued a smart card to the person who was linked by a database between the insurance providers and the health care providers.

It is expected that a professional person not only in the medical field but in general, should perform a fair, reasonable and competent degree of skill towards their work.
Thus, it is a must for the people in general, especially in the medical field to practice or apply their competent skills on clinical area. It is because in medical field, what is at stake there is a life of a human-being who is expecting proper care from any medical practitioner or health care provider. Medical interventions that are given by the medical practitioners include some necessary procedure to improve the health status of a certain patient. However, in some cases, some medical practitioners commits failure of observing the degree of care and awareness that a certain circumstance require, resulting now to the suffering or injury of another person, specifically, the recipient of care, who is the at risk or the subject of the committed failure. Medical negligence, though rarely, happens for real. It is when a particular practitioner did not take good care of the patient who is still under the medical care or a certain procedure in which a certain procedure, that is supposed to improve the health condition of the patient, unfortunately worsen or added to the injury of the patient. It is widely known as Negligence. Negligence is not actually intentional, rather than, it is only the failure of the health practitioner or a person in other field, to meet the necessary requirement particularly the degree of performance in giving interventions such as medical procedures to patients that have resulted into an untoward instance. It is connected with the word imprudence that means ‘lack of care’. Although this kind of failure is not intended by the health practitioner, it is still subjected and punishable by the law. Before the medical practitioners practice their profession, they are required to ought or pledged that they will not bring any harm to the recipient of their care. Henceforth, they are already verbally saying an agreement or a promise that they will give the appropriate care and protection expected from them of the recipient of medical care and not malicious or lax intervention.

Symposium based pieces and unsolicited manuscripts are published by JHCLP including student pieces composed by Journal staff members. Interested parties and organizations involving health care law are invited to contribute to the Journal.

Universal life care insurance is a globally accepted system to provide quality health care to citizens from all walks of life. It is a system by which basic health care expenses of a person are shared either completely by the government or partially by the government through a financial system of public-private partnership. In simple terms, when a person joins universal life care insurance, he or she will be provided free treatment either in hospitals run by the government or in certain hospitals stipulated by the government or the insurance scheme. Such a system is running efficiently in almost all developed countries in the world, especially in Europe and Asia. One notable exception from this group is United States.

Authorities dealing with health care insurance in United States maintain that there are a number of private companies in United States that provide a variety of health insurance. As a well-known apostle of free market and free economy, the US must provide an unregulated market environment for these companies to engage in a healthy competition so that the consumers will get maximum benefit. They insist that in the health care insurance system in the US, the consumer have a choice in selecting the insurance scheme.

The consumers can compare various insurance schemes and choose the best one according to their view. But many experts feel that the stance of the health care authorities does not take into consideration the situation prevailing at ground level. They argue that for a majority of people health insurance scheme is not their choice. For example, for employees of a private company, the company selects a particular health care insurance scheme and deducts the insurance premium from the salary of the employee. A fresh recruit to the company has no option but to select the insurance scheme of choice of that particular company. So the supposed advantage of insurance schemes of United States starkly reminds people of what Henry Ford, a great icon of capitalism, once said: “The customer can have any color as long as it is black.”

Another advantage of universal health care system is that every citizen of the country will come under a single scheme which will reduce the administrative costs significantly. A prominent health agency in United States, Institute of Medicine of the National Academies, pointed out several hidden costs in the present health insurance schemes, which ultimately decrease the quality of the health care and create further problems. Therefore, the institute has demanded for a universal health care insurance scheme in United States by 2010. In the present scenario, a person may not avail health care for certain health conditions because the insurance scheme he or she can afford does not support that kind of medical treatment. But every citizen of the country would benefit if a universal health care insurance scheme is put in place.