Services for healthcare have been on a steady incline for well over 10 years now. In 2012 a consumer alert was provided and according to it the healthcare industry provided $2.26 trillion in payments for over more than four billion healthcare insurance claims that were done in 2011. The majority of these claims were fraudulent and stem from professionals working in the Medicare system. Theses professional have lots of knowledge regarding the process and how to get new clients important information in hopes of deceiving and filing illegitimate healthcare claims. Some of the most advanced flaws in these claims are double billing, multiple billing, and fraudulent prescriptions, which has made our healthcare services crumble somewhat. Fraud is considered a non-violent crime which is more often committed by well educated people including but not limited to, physicians, medical administrators, business associates and hospital administration. Some healthcare claims come in so quickly that payments are expedited and then reused to medical providers. The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), One estimates that by the year 2015, health care spending will reach $4.0 trillion and will account for 20.0% of the Gross Domestic Product. Second with FY 2005 federal expenditures reaching $515 billion, and third, the Medicare and Medicaid programs comprise the largest single purchaser of health care in the world (McGuire & Schneider, 2007). Health care fraud is considered a demonstrated abuse and problem for our public treasury.
In the United States Health Care system, there have new ways in which payment methods are being made which is making things even more complicated. When referring to our healthcare system, it is considered to be a reimbursement industry. Reimbursement means that a repayment or such compensation of the requested healthcare services has been completed. Long-term care services are usually provided before a payment has been made. And because the patient’s treatment has already been completed, physicians, the medical facility, and also the staff all request to be reimbursed to cover expenses such as medical supplies, any medications, and also any procedures needed during the time of stay. All these expenses are submitted using an itemization listing all of the supplies and services rendered during the patient’s time of stay. This itemization form is also known as a claim form. All the fundamental specifics are listed on a claim such as, but not limited to, fees, and charges. There are two ways a claim can be reimbursed, a fee for service or capitation. Capitation is a fixed amount that is paid no matter the amount or costs of all the health care services that were provided. This way allows the incentive for lower costs so that providers to focus on preventive care more often. A fee of service is a set fee based on each type of health care service provided. The payable amount goes by what the payer considers a “normal” charge for the specific service provided. This gives providers an incentive to provide a better form of care that patients not only want, but also need. Most of health care fraud in the United States is committed healthcare providers that are dishonest (Groot & Massen, 2014).