Health systems Fraudulent Billing
Health systems Fraudulent Billing refers to the inappropriate payments that occur between healthcare providers, service users and other healthcare stakeholders such as the insurance companies. In the USA, this issue has gained popularity and has become major priority issue for health systems. Healthcare fraud can be classified into consumer fraud, provider fraud and insurer/payer fraud.
The most common type of fraud is provider healthcare fraud, and could be committed by dentists, physicians or provider organizations. The fraudulent behaviors can be diagnostic services, pharmaceutical services or manufacturers of medical device. Other fraudulent behaviors can involve other groups such as insurer representatives or patients (Rashidian, Joudaki, and Vian, 2012).
The healthcare systems are vulnerable to corruption and fraud. This is because many factors exacerbates the problem including inelastic demand for healthcare services, asymmetry of information between service users and service providers and the huge budget on healthcare (Joudaki et al., 2016). Despite the attentions paid to healthcare fraud by the political, administrative and legislative, combating it remains a huge struggle to the healthcare systems. The interventions to combat healthcare fraud aim at detecting, preventing and responding to fraudulent actions. Traditional methods of fraud detection rely mainly on auditing procedures which are not only time consuming but also ineffective (Rashidian, Joudaki, and Vian, 2012).
The article chosen for this topic is; Rashidian, .A, Joudaki, H., and Vian T. (2012). No Evidence of the Effect of the Interventions to Combat Health Care Fraud and Abuse: A Systematic Review of Literature. PLoS ONE 7(8): e41988. doi:10.1371/journal.pone.0041988
Rashidian and Joudaki conducted a systematic review on effectiveness of interventions to combat health systems fraudulent billing in US and Taiwan. The analysis of the available literature indicated some knowledge gap on effective strategies to eradicate healthcare fraud. The paper recommended for robust research in healthcare fraud in order to assess an effective intervention that will help to prevent, detect and react to fraudulent billing.
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2016). Improving Fraud and Abuse Detection in General Physician Claims: A Data Mining Study. International Journal of Health Policy and Management, 5(3), 165–172. http://doi.org/10.15171/ijhpm.2015.196
Rashidian, .A, Joudaki, H., and Vian T. (2012). No Evidence of the Effect of the Interventions to Combat Health Care Fraud and Abuse: A Systematic Review of Literature. PLoS ONE 7(8): e41988. doi:10.1371/journal.pone.0041988
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