Health care fraud: a primer on the schemes and the tools to fight health care fraud

As the national debate over health care reform moves forward, one issue with which policy makers must grapple is the percentage of health care dollars lost to fraud and abuse. The General Accounting Office estimates that as much as ten percent of total health care dollars are lost to the inappropriate, and in some cases criminal, practices of health care providers. This article discusses the characteristics of the health care industry that make it particularly susceptible to abuse and then reviews the efforts by the Office of Inspector General, Department of Health and Human Services, to deter and punish those who defraud the federal health care programs.     

Insurance Fraud

Insurance fraud is a major problem in the United States at the beginning of the 21st century. It has no doubt existed wherever insurance policies are written, taking different forms to suit the economic time and coverage available. From the advent of “railway spine” in the 19th century to “trip and falls” and “whiplash” in the 20th century, individuals and groups have always been willing and able to file bogus claims. The term fraud carries the connotation that the activity is illegal with prosecution and sanctions as the threatened outcomes. The reality of current discourse is a much more expanded notion of fraud that covers many unnecessary, unwanted, and opportunistic manipulations of the system that fall short of criminal behavior. Those may be better suited to civil adjudicators or legislative reformers. This survey describes the range of these moral hazards arising from asymmetric information, especially in claiming behavior, and the steps taken to model the process and enhance detection and deterrence of fraud in its widest sense. The fundamental problem for insurers coping with both fraud and systemic abuse is to devise a mechanism that efficiently sorts claims into categories that require the acquisition of additional information at a cost. The five articles published in this issue of the Journal of Risk and Insurance advance our knowledge on several fronts. Measurement, detection, and deterrence of fraud are advanced through statistical models, intelligent technologies are applied to informative databases to provide for efficient claim sorts, and strategic analysis is applied to property‐liability and health insurance situations.     

民间借贷与非法集资交叉案件裁判研究

民间借贷发轫于民间,其建立在个体信用基础之上,这种基于血缘、亲缘、地缘、业缘关系的个体信用容易监督,具有稳定性但不具有成长性。非法集资是以非法占有为目的,以虚构事实、隐瞒真相、虚假宣传的欺骗方法向不特定社会公众集资的犯罪行为。在我国,非法吸收公众存款、集资诈骗、高利转贷等相关联罪名均被列入非法集资。民间借贷与非法吸收公众存款、集资诈骗等刑事纠纷交织在一起,使当事人之间法律关系的性质难以准确判断,因此,民间借贷和非法集资刑民交叉案件成为司法实践中的＂疑难杂症＂,回答这个现实问题,会受到如金融机构、市场、监管机构、公安机关、司法裁判机构等一系列因素的影响。本文从交叉案件现象、交叉案件实体法律关系研究、交叉案件程序处理方式研究、交叉案件裁判研究四方面展开,归纳民间借贷和非法集资刑民交叉案件的法律要点和裁判要旨,形成判断罪与非罪、罪轻与罪重的司法指引。     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

New development: New global health care PPP developments—a critique of the success story

Health care public–private partnerships (PPPs), where clinical services as well as infrastructure are delivered by the private sector, are coming under the spotlight as governments seek to achieve value for money in health budgets. Existing examples have been widely reported as successful. However, this article urges caution as a closer look at the evidence shows that handing over control of service delivery to the private sector is difficult to monitor and evaluate, carries cost implications which remain largely unquantified and can create additional risk.     

民事欺诈与刑事诈骗的类型化区分

刑事诈骗是民事欺诈中的严重部分,两者最主要的区别在于行为人主观上是否具有非法占有目的。刑事诈骗的行为类型多样,具体构造也存在一定差异,非法占有目的的认定应结合诈骗行为的具体构造展开。交易型诈骗中,作为交易对价的基础事实是否存在对于非法占有目的认定具有决定意义。使用型诈骗的场合,应重视对行为人取得财物后的用途和资金走向的考察,以确定非法占有目的是否成立。财物用途和资金走向无法查清的案件,不能简单地认为属于事实不清、证据不足。资格型诈骗中,非法占有目的的认定应同时考虑行为人是否具有特定资格以及财物的具体用途。民事欺诈与刑事诈骗的区分还要注意欺诈事实是否属于核心或者主要事实以及欺诈程度等。     

Public Versus Private: The Empty Definitions of National Accounting

The policy-making processes and the policies of the two international systems of national accounts are addressed, from the perspective of the accounting discipline. The particular measurement issue that determines which parts of an economy are public and which are private - the reporting entity - is discussed. The main conclusion is that the definition of the reporting entities is so vague as to be empty; in other words, national accounting's definition of what is public and what is private is empty.     

Internal audit,alternative internal audit structures and the level of misappropriation of assets fraud

In recent years, the importance of good corporate governance has received significant public and regulatory attention. A crucial part of an entity's corporate governance is its internal audit function. At the same time, there has been significant public concern about the level of fraud within organizations. The purpose of this study is to assess whether organizations with an internal audit function are more likely to detect and self‐report fraud than those without. In this study, we use a unique self‐reported measure of misappropriation of assets fraud for the first time. The fraud data are from the 2004 KPMG Fraud Survey, which reported fraud from 491 organizations in the private and public sector across Australia and New Zealand. The internal audit data are from a separate mail survey sent to the respondents of the KPMG Fraud Survey. We find that organizations with an internal audit function are more likely than those without such a function to detect and self‐report fraud. Furthermore, organizations that rely solely on outsourcing for their internal audit function are less likely to detect and self‐report fraud than those that undertake at least part of their internal audit function themselves. These findings suggest that internal audit adds value through improving the control and monitoring environment within organizations to detect and self‐report fraud. These results also suggest that keeping the internal audit function within the organization is more effective than completely outsourcing that function.     

Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries

In an earlier article, the authors outline some reasons forthe disappointingly small effects of primary health care programsand identified two weak links standing between spending andincreased health care. The first was the inability to translatepublic expenditure on health care into real services due toinherent difficulties of monitoring and controlling the behaviorof public employees. The second was the "crowding out" of privatemarkets for health care, markets that exist predominantly atthe primary health care level. This article presents an approach to public policy in healththat comes directly from the literature on public economics.It identifies two characteristic market failures in health.The first is the existence of large externalities in the controlof many infectious diseases that are mostly addressed by standardpublic health interventions. The second is the widespread breakdownof insurance markets that leave people exposed to catastrophicfinancial losses. Other essential considerations in settingpriorities in health are the degree to which policies addresspoverty and inequality and the practicality of implementingpolicies given limited administrative capacities. Prioritiesbased on these criteria tend to differ substantially from thosecommonly prescribed by the international community.      

Public/private health care: The British scenario

The issue of public versus private health care is too often treated as an ideological issue, with each side unwilling to discuss common problems of cost containment and quality control which have to be faced, no matter what the financial framework. Thus, cost containment will worry the administrators of insurance funds just as much, if not more, than health service administrators. Health care is not, in the economist's sense, a perfect market; it cannot and does not remain unregulated. So what is at issue is whether regulation is carried out by government, by insurance companies, or by the professions, and what the balance between them shall be.

These and other lessons are drawn from a series of studies describing the workings of insurance systems in a number of countries, in Europe, as well as the United States, Canada and Australia. The findings of the book ‐ The Public/Private Mix for Health, edited by Gordon McLachlan and Alan Maynard, and published this autumn by the Nuffield Provincial Hospitals Trust ‐ are too rich to be summarised here. What follows is an extract from the final chapter containing the editors’ own reflections on the material they have brought together.     

For fraud,look under ‘serious and organized crime’

ABSTRACT

The UK government’s response to fraud cannot be disentangled from its broader ‘serious and organized crime’ (SOC) strategy. In order to explore whether fraud should—in public policy, criminal justice and law enforcement terms—be seen primarily as an SOC issue, there is a need to consider questions about whether or not ‘SOC’ is a sensible object of policy-making in the first place. Several arguments in favour of an SOC policy are identified in the paper. However, the notion of an overarching SOC policy is problematic for three reasons. First, SOC is a fundamental misrepresentation of reality, which does not correspond to a real social problem. Second, SOC policy can limit the development of more problem-specific crime strategies, Third, the ‘SOC’ label can negatively transform how social problems are perceived over the long term. If fraud is to be better understood and dealt with, it may therefore be necessary to extract it from its current inclusion within wider SOC strategy.     

The interdependencies of intra- and inter-organisational controls and work practices—The case of domestic care of the elderly

The paper gives a grounded account of inter-organisational controls and work practices in the public sector to complement previous literature's strong focus on inter-organisational customer–supplier relationships in the private sector. We draw theoretically on Hopwood's (1974) administrative, social and self controls, which enable us to analyse the influence of non-managerial controls on behaviour. Empirically, a case study of inter-organisational cooperation between home help units and health centres is used as the basis of analysis. Most inter-organisational controls were developed locally and involved a mix of administrative, social and self controls. Intra- and inter-organisational social and self controls were important forms of control which impacted on intra- and inter-organisational work practices and we see the need for a broad conceptualisation of control (Van der Meer-Kooistra and Scapens, 2008). Inter-organisational social controls created an informal hierarchy that by-passed the formal hierarchies of the two organisations. Self controls reinforced the importance of being flexible to accommodate pensioner's wishes and needs in specific care situations. We also show the importance of the internal financial situation of home help units for the analysis of the interdependencies of intra- and inter-organisational controls and work practices.     

A contingency theory perspective on the risk management control system within Birmingham City Council

In recent years the topic of risk management has moved up the agenda of both government and industry, and private sector initiatives to improve risk and internal control systems have been mirrored by similar promptings for change in the public sector. Both regulators and practitioners now view risk management as an integral part of the process of corporate governance, and an aid to the achievement of strategic objectives.The paper uses case study material on the risk management control system at Birmingham City Council to extend existing theory by developing a contingency theory for the public sector. The case demonstrates that whilst the structure of the control system fits a generic model, the operational details indicate that controls are contingent upon three core variables—central government policies, information and communication technology and organisational size. All three contingent variables are suitable for testing the theory across the broader public sector arena.     

Prosecuting Insurance Fraud—A Case Study of the Massachusetts Experience in the 1990s

There is widespread agreement that insurance fraud is a major problem in the United States. There is little agreement, however, in what constitutes insurance fraud in the many articles and research papers published on the subject during the past ten years. The term ‘‘fraud’’ carries the connotation that the activity is illegal and, hence, that prosecution and conviction are potential outcomes of a specific fraud. Accepting that premise allows us to adopt the legal definition of fraud in the insurance context and to examine the experience of dealing with insurance fraud in terms of property‐liability insurance lines. Specifically, we examine ten years of data on referrals and disposals of incidents of suspected fraud as processed by the Insurance Fraud Bureau of Massachusetts to provide estimates of the distribution of types of people who perpetrate a variety of insurance frauds. We compile conviction rates, sentencing outcomes, and recidivism rates in detail to illuminate the law enforcement process and to gauge the deterrent effect of prosecuting insurance fraud in the criminal courts. The Massachusetts data lead us to conclude that the number of cases of convictable fraud is much smaller than the prevailing view of the extent of fraud; that the majority of guilty subjects have prior (noninsurance) criminal records; and that sentencing of subjects guilty of insurance fraud appears effective as both a general and specific deterrent for insurance fraud but ineffective as a specific deterrent for other crime types, as the recidivism rate appears no different from the general property criminal's recidivism rate.     

The public sector and health care

This paper specifies a model of the determinans of total expenditure on health care. The model shows how this expenditure is divided between the public and private sectors when public expenditures are chosen by majority rule.From the theoretical model I derive two equations determining the private and public expenditures on health care as shares of GDP. The equations are estimated using OECD panel data with two-way fixed effects and with simultaneous correction for heteroeskedasticity and serial correlation. The results include estimates of the price and income elasticities of public and private demands for health care as well as estimates of the crowdingout effects of public on private expenditures.Paper presented at the 51st Congress of the International Institute of Public Finance.     

Accounting control,governance and anti-corruption initiatives in public sector organisations

This special issue focuses on the interactions between accounting, public sector organisations and the socio-economic and political environments in which they operate, with a specific focus on the critical analysis of policy and practice in the fight against corruption. The aim of the special issue is to disseminate knowledge to enable a more sustainable, accountable and less corrupt public sector, regardless of where it is located in the world. It presents the work of a global community of scholars engaged in research projects on policies and strategies related to accountability, transparency, auditing, regulatory disclosure, governance, investor protection and anti-corruption initiatives in public sector organisations. The papers presented here address many different angles of corruption and aspects of the way in which it is reported using a broad range of methodologies, theoretical frameworks and research locations. Collectively, these papers demonstrate that more attention needs be given to investigating the human cost associated with illegal activity that leads to human suffering, inequality, and lifetime costs. They further emphasise that we have much to learn about regulatory disclosure and jurisprudential practice in the fight against fraud and corruption.     

The influence of remuneration on the behavior of hospital employees in Brazil

The study aimed to analyze the employee's perception of the remuneration systems in two major hospitals in Brazil, one managed by the government and the other by private investors. The sample considered 109 respondents, out of which 54 were from the private hospital and 55 from the public hospital. After data collection on the sample population, perception of remuneration was associated with occupation, gender, age and experience, as suggested by the Upper Echelons Theory. The results show that remuneration is viewed as an instrument of control and behavior or a learning-inducing mechanism; however, the perceptions of employees working in the health area and administrative area were different. These findings show that the influence of fixed pay is different not only for the employees of both areas, but also in relation to the public and private hospital management. It was found that gender is not a determinant factor of behavior and that there were no differences between younger and older employees as well as between more experienced and less experienced employees with respect to the effect of remuneration on behavior. There were no differences in relation to the type of hospital either. In general, the results emphasize the importance of remuneration as an instrument of control and management, either in the context of public or private organizations.     

论公共卫生最优支出策略

公共卫生支出具有极强的正外部性.如果由地方政府或私人选择公共卫生支出的水平,那么他们的最优选择是较低的公共卫生支出和较高的个人消费(内含个人医疗支出),整个社会的福利将会处于较低的水平状态.本文在一个动态的框架下分析了发生这种现象的经济学原因,说明中央政府而非地方政府或私人应该对公共卫生的建设承担更大的责任,应由中央政府负责全国公共卫生体系的建设.     

Designing a guideline-based utilization management program

Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.     

Retiree health benefits in the United States: a strategic critical management review

This article provides a critical review of studies associated with retiree health benefits in the United States. An attempt is made to determine if logical conclusions or trends could be identified regarding this issue of health care policy debate. The forms of retiree health benefits are covered, as is a discussion of Medigap policies and insurance coverage for the elderly. Employer-sponsored retiree benefits and the effects of supplemental coverage on the use of services are also reviewed. Lastly, a discussion and conclusion regarding this research agenda is presented with a critical analysis of the health care policy management debate for the future.