Heath care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Health care schemes come in many different forms like: billing by practitioners for care that they never rendered, filing duplicate claims for the same service rendered, altering the dates, description of services, or identities of members or providers, modifying medical records, intentional incorrect reporting of diagnoses or procedures to maximize payment, prescribing additional or unnecessary treatment. In this paper, I will examine the Multi-Million-Dollar Health Care fraud that was committed by one surgeon, who worked in NY hospital. I will ...view middle of the document...
Analysis and Prevention.
A false billing scheme is always carried out in service account categories like professional fees. Because it is harder to prove a service was not performed as opposed to trying to conceal a good that was never purchased or received. The service being falsely billed would be either nonexistent or unnecessary. In this case, Panos was not performing services but was billing customers. It was hard to prove that service was not performed due to the nature of business. One of his patients with the knee surgery however, proved it by the X-ray, which showed that nothing was done to it. (Sarah Bradshaw, 2013)
Fraud triangle helps to explain the nature of many occupational offenders. In most fraudulent acts, there are three circumstances lead to the commission of fraud: pressure, opportunity, rationalization. Pressure is the first step in the fraud triangle. This case did not give any description of his needs or intends of stealing so much money that is why I assumed that the pressure was his lifestyle. His patients filed almost 260 lawsuits against him and it did not make him stop his fraudulent activity. Probably he had to pay for his high-end lifestyle (nice car, house etc.).
Regardless of strength of pressure, fraud will definitely take place if the opportunity is presented. Opportunity is the only step where company has control. If company will reduce the opportunity by straightening internal controls, the possibility of the fraud to occur is decreasing. He wasn’t watched by anybody while his surgeries so he could write anything on the report. Certain types of segregation of duties should be presented in surgery practices. Usually the person assisting the doctor make notes and help the doctor with maintaining records. However, doctor Panos was keeping records himself and they just showed the times of surgeries and administering of anesthesia but did not contain a description of the procedures or names of the patients. Therefore, after surgeries Panos could easily make up some procedures as being performed.
The last step in the triangle is rationalization. One type of rationalization is when people do not care about consequences. I think this one would fit this case. I know that doctors make a lot of money and this case did not specify doctor’s problems or addictions. Knowing this I assumed that he was too greedy and could not stop stealing.
The biggest part in the prevention of this scheme falls on patients, and the rest of it on the Hospital internal controls.
- The segregation of duties should be in place. By proper hospital internal controls, the same person cannot handle patients and billing them.
- Internal audit should be performed yearly.
-Every patient after care should review the statement to verify the accuracy. In Health Care industry, it...