Preventing healthcare fraud and abuse is critical to maintaining the integrity of healthcare systems, protecting patients and protected health information (PHI), and ensuring resources are used efficiently and appropriately. Health care fraud is intentional deception or misrepresentation for the purpose of obtaining fraudulent benefits or payments. Medical malpractice, on the other hand, involves acts that violate accepted medical, tax, or legal standards, but may be unintentional.
Here are some important things to know to prevent healthcare fraud and abuse.
Types of Healthcare Fraud and Abuse
Billing Fraud:
False Claims:
Kickbacks and Bribes:
Prescription Fraud:
Upcoding and Unbundling:
Consequences of Healthcare Fraud and Abuse
Measures to Prevent Health Care Fraud and Abuse
- Health Care Provider Education
- Monitoring and Auditing
- Compliance Program
- Whistleblower Protection
- Data Analytics
- Vendor Credentials
- Patient Education
Report Healthcare Fraud or Misconduct
If you suspect healthcare fraud or fraud, you should report it. You can contact your state’s Department of Health and Human Services (HHS) Office of Inspector General (OIG) or Medicare Fraud Enforcement Unit (MFCU). Additionally, most healthcare organizations have hotlines and reporting mechanisms that allow employees and patients to anonymously report suspected misconduct.
Preventing healthcare fraud and abuse is a shared responsibility of healthcare providers, patients, and regulators. By remaining vigilant and taking proactive measures, the healthcare industry can work together to maintain a reliable and sustainable healthcare system.
