Medical professionals and health care fraud: Do they aid or check abuse?

Goel, Rajeev K.

doi:10.1002/mde.3117

Cited by 4 publications

(14 citation statements)

References 23 publications

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“…Physicians' focus is primarily on diagnosis, while nurses have a greater attention to medical records. This result supports earlier findings in the literature (Goel, 2020).…”

Section: Estimationsupporting

confidence: 94%

“…Our baseline models in Table 2 examine the determinants of health care scams, without considering the border or contagion effects. The four models presented consider different combinations of possible drivers of health scams, borrowing from the literature (Goel, 2020) and the related discussion above. The overall fit of the three models is decent as shown by the R 2 s and the statistically significant F ‐values.…”

Section: Resultsmentioning

confidence: 99%

“…Given the cross-sectional nature of our data with observations for the 50 states and the District of Columbia, some outlier state(s) (e.g., a state with no health scams or ones with unusually high scams) could (Goel, 2020) and the related discussion above. The overall fit of the three models is decent as shown by the R 2 s and the statistically significant F-values.…”

Section: Estimationmentioning

confidence: 99%

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Are health care scams infectious? Empirical evidence on contagion in health care fraud

Goel

2020

Manage Decis Econ

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This paper examines the presence of contagion in health care fraud across jurisdictional boundaries. Using state‐level data for the United States, we find evidence of contagion in medical fraud. There are also spillovers from border corruption on medical fraud, but no evidence of spillovers from international borders. In other findings, greater urbanization, greater elderly population, and higher hospital occupancy positively contribute to medical fraud, while nursing employment has a mitigating effect. Further, it is economic inequality rather than economic prosperity that seems relevant. The main findings are robust to consideration of simultaneity, but dependent upon the prevalence of fraud across states.

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“…Physicians' focus is primarily on diagnosis, while nurses have a greater attention to medical records. This result supports earlier findings in the literature (Goel, 2020).…”

Section: Estimationsupporting

confidence: 94%

Section: Resultsmentioning

confidence: 99%

Section: Estimationmentioning

confidence: 99%

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Are health care scams infectious? Empirical evidence on contagion in health care fraud

Goel

2020

Manage Decis Econ

Self Cite

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“…This situation can occur with or without the knowledge of the owner. (r) (Baltussen et al, 2006 ; Dolan & Farmer, 2016 ; Goel, 2020 ; Jator & Hughley, 2014 ; Johnson & Nagarur, 2016 ; Li et al, 2008 ; Sheffali & Deepa, 2019 ; Shin et al, 2012 ) Doctor shopping Patients seek to stock up on controlled substances or drugs. (s) (Sheffali & Deepa, 2019 ) Misrepresenting eligibility Patients can misrepresent information about themselves or their dependents to obtain medical coverage, which is not eligible.…”

Section: Resultsmentioning

confidence: 99%

“… (Jator & Hughley, 2014 ) Types of health professionals Health professionals are effective in controlling fraud in medical care. (Goel, 2020 ) For each study, we denote with a positive sign (+) when the factor increases the HIF, and a negative sign (−) if the factor reduces the HIF; when used a single sign, it indicates that the study proved a theoretical or narrative contribution. A factor can show both signs simultaneously (+−), which means that its influence is ambivalent.…”

Section: Resultsmentioning

confidence: 99%

Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review

2021

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Background Healthcare fraud entails great financial and human losses; however, there is no consensus regarding its definition, nor is there an inventory of its manifestations and factors. The objective is to identify the definition, manifestations and factors that influence health insurance fraud (HIF). Methods A scoping review on health insurance fraud published between 2006 and 2020 was conducted in ACM, EconPapers, PubMed, ScienceDirect, Scopus, Springer and WoS. Results Sixty-seven studies were included, from which we identified 6 definitions, 22 manifestations (13 by the medical provider, 7 by the beneficiary and, 2 by the insurance company) and 47 factors (6 macroenvironmental, 15 mesoenvironmental, 20 microenvironmental, and 6 combined) associated with health insurance fraud. We recognized the elements of fraud and its dependence on the legal framework and health coverage. From this analysis, we propose the following definition: “Health insurance fraud is an act of deception or intentional misrepresentation to obtain illegal benefits concerning the coverage provided by a health insurance company”. Among the most relevant manifestations perpetuated by the provider are phantom billing, falsification of documents, and overutilization of services; the subscribers are identity fraud, misrepresentation of coverage and alteration of documents; and those perpetrated by the insurance company are false declarations of benefits and falsification of reimbursements. Of the 47 factors, 25 showed an experimental influence, including three in the macroenvironment: culture, regulations, and geography; five in the mesoenvironment: characteristics of provider, management policy, reputation, professional role and auditing; 12 in the microenvironment: sex, race, condition of insurance, language, treatments, chronic disease, future risk of disease, medications, morale, inequity, coinsurance, and the decisions of the claims-adjusters; and five combined factors: the relationships between beneficiary-provider, provider-insurance company, beneficiary-insurance company, managers and guānxi. Conclusions The multifactorial nature of HIF and the characteristics of its manifestations depend on its definition; Identifying the influence of the factors will support subsequent attempts to combat HIF.

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From Allegations to Actions: Examining the Impact of Fraud Reporting Mechanisms in Healthcare

Amponsah

2024

Preprint

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Introduction: The U.S. healthcare sector is characterized by a diverse mix of public and private funding and provision, resulting in a lack of a singular governing philosophy. Both the public and private sectors are known for providing high-quality medical services. However, since 1980, healthcare spending in the U.S. has substantially increased. The immense size and financial resources of the healthcare sector make it a prominent target for fraudulent activities. Aim This study investigated the impact of collaborative efforts between managed care organizations (MCOs) and oversight agencies on the detection and reduction of healthcare fraud within the Illinois Medicaid program. Method This study examines how collaboration between MCOs and oversight agencies impacts healthcare fraud in Illinois Medicaid. A FOIA request for complaint data was sent to the Illinois Department of Healthcare and Family Services. The Illinois Medicaid Office of the Inspector General oversees program integrity and maintains e database to prevent the enrollment of excluded providers. Results As of September 20, 2023, 2,741 providers were sanctioned, including 857 physicians, 679 waiver service providers, 159 pharmacies, and 157 Medicare providers. Over the period from September 2022 to August 2023, 1,059 fraud referrals were recorded, with internal data mining contributing the most (448) and County Care being the top-referring MCO (260 cases). The collaborative efforts between MCOs and the Medicaid – Office of Inspector General led to the identification of $23,830,110 in questioned costs, resulting in a recovery of $13,441,726 in fiscal year 2021. Conclusion/Recommendation: The findings emphasize the significance of data sharing and transparency in the fight against fraud. The imposition of sanctions on errant healthcare providers has emerged as a key deterrent against fraudulent activities. To combat fraud and information gaps, a comprehensive strategy is needed. This includes empowering patients, improving communication, using advanced analytics, and enforcing regulations. User-friendly digital platforms provide reliable information, enabling informed decisions and reducing disparities. Strengthened collaboration and advanced analytics are crucial for early fraud detection, preserving healthcare integrity, and preventing financial losses.

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Medical professionals and health care fraud: Do they aid or check abuse?

Cited by 4 publications

References 23 publications

Are health care scams infectious? Empirical evidence on contagion in health care fraud

Are health care scams infectious? Empirical evidence on contagion in health care fraud

Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review

From Allegations to Actions: Examining the Impact of Fraud Reporting Mechanisms in Healthcare

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