Fraud Asuransi Kesehatan (FRD)

Selayang Pandang: Fraud Pelayanan Kesehatan

Usaha-Usaha Anti-Fraud Perusahaan Asuransi

Investigasi Kriminal dan Usaha-Usaha Anti Kecurangan Pemerintah

Teknik Investigasi dan Preparasi Kasus

Otomatisasi Untuk Penyelidikan

Kecurangan Dalam Tatanan Managed Care

Kecurangan dalam Perpindahan Data Elektronik

Administrasi Klaim Biaya Medis

Kecurangan Dalam Sektor Disabilitas Pendapatan

The Challenge of Health Care Fraud

Consumer Alert: The Impact of Health Care Fraud on You!

In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in

the United States. It is an undisputed reality that some of these health insurance claims are fraudulent. Although they

constitute only a small fraction, those fraudulent claims carry a very high price tag.

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care

fraud are in the tens of billions of dollars each year.

Whether you have employer-sponsored health insurance or you purchase your own insurance policy, health care

fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced

benefits or coverage. For employers-private and government alike-health care fraud increases the cost of providing

insurance benefits to employees and, in turn, increases the overall cost of doing business. For many Americans, the

increased expense resulting from fraud could mean the difference between making health insurance a reality or not.

However, financial losses caused by health care fraud are only part of the story. Health care fraud has a human face

too. Individual victims of health care fraud are sadly easy to find. These are people who are exploited and subjected

to unnecessary or unsafe medical procedures. Or whose medical records are compromised or whose legitimate

insurance information is used to submit falsified claims.

 Don't be fooled into thinking that health care fraud is a victimless crime. There is no doubt that health care fraud can

have devastating effects.

What Does Health Care Fraud Look Like?

The majority of health care fraud is committed by a very small minority of dishonest health care providers. Sadly,

the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected

members of our society-our physicians.

Unfortunately, the stock in trade of fraud-doers is to take advantage of the confidence that has been entrusted to

them in order to commit ongoing fraud on a very broad scale. And in conceiving fraud schemes, this group has the

luxury of being creative because it has access to a vast range of variables with which to conceive all sorts of

wrongdoing:
 The entire population of our nation's patients;

 The entire range of potential medical conditions and treatments on which to base false claims; and

 The ability to spread false billings among many insurers simultaneously, including public programs such
as Medicare and Medicaid, increasing fraud proceeds while lessening their chances of being detected by
any a single insurer.

The most common types of fraud committed by dishonest providers include:

 Billing for services that were never rendered-either by using genuine patient information, sometimes
obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures
or services that did not take place.

 Billing for more expensive services or procedures than were actually provided or performed, commonly
known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which
often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition
consistent with the false procedure code).

 Performing medically unnecessary services solely for the purpose of generating insurance payments-
seen very often in nerve-conduction and other diagnostic-testing schemes.

 Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of

obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic
procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.

 Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically
necessary.

 Unbundling - billing each step of a procedure as if it were a separate procedure.

 Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit
plan under the terms of a managed care contract.

 Accepting kickbacks for patient referrals.

 Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or
benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider
contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be
waived due to "financial hardship").

Consider Some Risks of Health Care Fraud to You

False Patient Diagnoses, Treatment and Medical Histories

Health care fraud, like any fraud, demands that false information be represented as truth. An all too common health

care fraud scheme involves perpetrators who exploit patients by entering into their medical records false diagnoses

of medical conditions they do not have, or of more severe conditions than they actually do have. This is done so that

bogus insurance claims can be submitted for payment.

Unless and until this discovery is made (and inevitably this occurs when circumstances are particularly challenging

for a patient) these phony or inflated diagnoses become part of the patient's documented medical history, at least in

the health insurer's records.

A Boston-area psychiatrist, for example, forfeited $1.3 million and was sentenced to several years in federal prison
following his late-1990s conviction on 136 counts of mail fraud, money laundering and witness intimidation related
to his fraudulent billing of several health insurers for psychiatric therapy sessions that never took place-using the
names and insurance information of many people whom he actually had never met, let alone treated. (He also went
so far as to write fictitious longhand session notes to ensure phony backup for his phony claims. )

In fabricating the claims, the psychiatrist also fabricated diagnoses for those "patients"-many of them adolescents.
The phony conditions he assigned to them included "depressive psychosis," "suicidal ideation," "sexual identity
problems" and "behavioral problems in school."

Theft of Patients' Finite Health Insurance Benefits

Patients who have private health insurance often have lifetime caps or other limits on benefits under their policies.

So every time a false claim is paid in a patient's name, the dollar amount counts toward that patient's lifetime or

other limits. This means that when a patient legitimately needs his or her insurance benefits the most, they may have

already been exhausted.

Medical Identity Theft

As a consumer, you are surely aware of the perils of identity theft and the devastating affects it can have on your

financial health-jeopardizing bank accounts, credit ratings and your ability to borrow. But are you as familiar with

the risks posed by medical identity theft? You should be, considering that 250,000 to 500,000 individuals have been

victims of this escalating crime.

When a person's name or other identifying information is used without that person's knowledge or consent to obtain

medical services or goods, or to submit false insurance claims for payment, that's medical identity theft. Medical
identity theft frequently results in erroneous information being added to a person's medical record, or even the

creation of an entirely fictitious medical record in the victim's name.

Victims of medical identity theft may receive the wrong medical treatment, find that their health insurance benefits

have been exhausted, and could become uninsurable for both life and health insurance coverage.

A medical identity theft victim may unexpectedly fail a physical exam for employment because a disease or

condition for which he's never been diagnosed or received treatment has been unknowingly documented in his

health record.

Untangling the web of deceit spun by perpetrators of medical identity theft can be a grueling and stressful endeavor.

The effects of this crime can plague a victim's medical and financial status for years to come.

Physical Risk to Patients

Shockingly, the perpetrators of some types of health care fraud schemes deliberately and callously place trusting

patients at significant risk of injury or even death. It's distressing to imagine, but there have been many cases where

patients have been subjected to unnecessary or dangerous medical procedures simply because of greed.
In June, 2002, for example, a Chicago cardiologist was sentenced to 12-1/2 years in federal prison and was ordered
to pay $16.5 million in fines and restitution after pleading guilty to performing 750 medically unnecessary heart
catheterizations, along with unnecessary angioplasties and other tests as part of a 10-year fraud scheme.

Three other physicians and a hospital administrator also pleaded guilty and received prison sentences for their part
in the scheme, which resulted in the deaths of at least two patients.

The physicians and hospital induced hundreds of homeless persons, substance abusers, and elderly men and women
to feign symptoms and be admitted to the hospital for the unnecessary procedures. How? By offering them incentives
such as food, cash and cigarettes. "There were 750 people who had needles stuck into their hearts purely for profit,
not because they needed it," said one of the federal prosecutors.

Health Care Fraud and Organized Criminal Groups

Health care fraud is not just committed by dishonest health care providers. So enticing an invitation is our nation's

ever-growing pool of health care money that in certain areas - Florida, for example - law enforcement agencies and

health insurers have witnessed in recent years the migration of some criminals from illegal drug trafficking into the

safer and far more lucrative business of perpetrating fraud schemes against Medicare, Medicaid and private health

insurance companies.

In South Florida alone, government programs and private insurers have lost hundreds of millions of dollars in recent

years to criminal rings - some of them based in Central and South America - that fabricate claims from non-existent

clinics, using genuine patient-insurance and provider-billing information that the perpetrators have bought and/or
stolen for that purpose. When the bogus claims are paid, the mailing address in most instances belongs to a freight

forwarder that bundles up the mail and ships it off shore.

A Federal Crime with Stiff Penalties

In response to these realities, Congress-through the Health Insurance Portability and Accountability Act of 1996

(HIPAA)-specifically established health care fraud as a federal criminal offense, with the basic crime carrying a

federal prison term of up to 10 years in addition to significant financial penalties. [United States Code, Title 18,

Section 1347.]

The federal law also provides that should a perpetrator's fraud result in the injury of a patient, the prison term can

double, to 20 years; and should it result in a patient's death, a perpetrator can be sentenced to life in federal prison.

Congress also mandated the establishment of a nationwide "Coordinated Fraud and Abuse Control Program," to

coordinate federal, state and local law enforcement efforts against health care fraud and to include "the coordination

and sharing of data" with private health insurers.

Many states also have responded vigorously since the early 1990s, not only by strengthening their insurance fraud

laws and penalties, but also by requiring health insurers to meet certain standards of fraud detection, investigation

and referral as a condition of maintaining their insurance or HMO licenses.

Private-Public Cooperation Against Fraud is Essential

Founded in 1985 by a handful of private insurers and law enforcement personnel, the National Health Care Anti-

Fraud Association is a private-public non-profit organization focused solely on improving the private and public

sectors' ability to detect, investigate, prosecute and, ultimately, prevent fraud against our private and public health

insurance systems.

Today NHCAA represents the combined efforts of the anti-fraud units of the majority of our country's private health

payers and the entire spectrum of federal and some state law enforcement agencies that have jurisdiction over the

crime, along with hundreds of individual members from the private health insurance sector and from federal, state

and local law enforcement.

The NHCAA pursues its mission by fostering private-public cooperation against health care fraud at both the case

and policymaking levels, by facilitating the sharing of investigative information among health insurers and law

enforcement agencies and by providing information on health care fraud to all interested parties.

The NHCAA Institute for Health Care Fraud Prevention, a non-profit educational foundation, provides professional

education and training to industry and government anti-fraud investigators and other personnel.
 What Can You Do To Avoid or Prevent Health Care Fraud?

Here are some simple ways you can protect yourself from health care fraud, and keep health care costs down for

everyone:
 Protect your health insurance ID card like you would a credit card. In the wrong hands, a health insurance
card is a license to steal. Don't give out policy numbers to door-to-door salespeople, telephone solicitors
or over the Internet. Be careful about disclosing your insurance information and if you lose your insurance
ID card, report it to your insurance company immediately.

 Report fraud. Call your insurance company immediately if you suspect you may be a victim of health
insurance fraud. Many insurers now offer the opportunity to report suspected fraud online through their
Website.

 Be informed. Be informed about the health care services you receive, keep good records of your medical
care, and closely review all medical bills you receive.

 Read your policy and benefits statements. Read your policy, Explanation of Benefits (EOB) statements
and any paperwork you receive from your insurance company. Make sure you actually received the
treatments for which your insurance was charged, and question suspicious expenses. Are the dates of
service documented on the forms correct? Were the services identified and billed for actually performed?

 Beware of "free" offers. Is it too good to be true? Offers of free health care services, tests or treatments
are often fraud schemes designed to bill you and your insurance company illegally for thousands of
dollars of treatments you never received.

Health care fraud is a serious crime that affects everyone and should concern everyone-government officials and

taxpayers, insurers and premium-payers, health care providers and patients-and it is a costly reality that none of us

can afford to overlook.

For more information on health care fraud, please visit the links below.

 Consumer Info & Action

 Consumer Alert: Don't Be Scammed
 Consumers' Frequently Asked Questions

Types of Healthcare Fraud

Healthcare fraud affects three major types of insurance: accident and health, private disability,
and no-fault. The more common types of healthcare fraud include:
· Prescription drug diversion and misuse;
· Medical identity fraud;
· Billing for services that were never rendered and products that were not provided;
Billing for more expensive procedures or services than were actually provided,
commonly known as upcoding;
· Performing medically unnecessary treatments and expensive diagnostic tests for the sole
purpose of generating insurance payments;
· Misrepresenting non-covered treatments as medically necessary covered treatments, for
example billing a cosmetic nose surgery as a deviated septum repair, to obtain insurance
payments;
· Unbundling — billing as if each step of a procedure were a separate procedure;
· Staging or causing auto accidents;
· Filing no-fault claims for nonexistent injuries;
· Filing false or exaggerated medical disability claims;
· Staging slip-and-fall accidents;
· Accepting kickbacks for patient referrals.

Istilah fraud disebut juga fraude (Belanda) atau concealment atau “kecurangan” dalam terminologi
bahasa Indonesia. Definisi Fraud menurut beberapa literatur adalah sebagai berikut:
The definition of fraud means concealment or
1. Green & Rowell (2011) define fraud from HIPAA (The Health Insurance Portability and
Accountability Act) by definition as follow“an intentional deception or misrepresentation that
someone makes, knowing it is false, that could result in an unauthorized payment”.
2. According to Todd (2009) in the book “The Managed Care Contracting Handbook Planning and
Negotiating the Managed Care Relationship”, Fraud is :
a. Intentional misrepresentations that can result in criminal prosecution, civil liability, and
administrative sanctions.

Intentional lying or concealment by policyholders to obtain payment of an insurance claim that

would otherwise not be paid, or lying or misrepresentation by the insurance company managers,
employees, agents, and brokers for financial gain

Fraud is intentional breach of the standard of good faith and fair dealing, as understood in the
community, involving deception or breach of trust, for money.

http://www.helpstopfraud.org/Types-of-Insurance-Fraud/Health

In this type of fraud‚ false or misleading information is

provided to a health insurance company in an attempt to
have them pay unauthorized benefits to the policy holder‚
another party‚ or the entity providing services. The offense
can be committed by the insured individual or the provider
of health services.
An individual subscriber can commit health insurance fraud by:
 allowing someone else to use his or her identity and insurance information to obtain health care
services
  using benefits to pay for prescriptions that were not prescribed by his or
her doctor
Health care providers can commit fraudulent acts by:
 billing for services‚ procedures and/or supplies that were never rendered
 charging for more expensive services than those actually provided
 performing unnecessary services for the purpose of financial gain
 misrepresenting non–covered treatments as a medical necessity
 falsifying a patient’s diagnosis to justify tests‚ surgeries‚ or other procedures
 billing each step of a single procedure as if it were a separate procedure
 charging a patient more than the co–pay agreed to under the insurer’s terms
 paying “kickbacks” for referral of motor vehicle accident victims for treatment
Examples
Here are a few typical scenarios to illustrate some of the different ways health insurance fraud
can be committed:
Chris was the only one in his family with health insurance, but he let his brother and cousin use his card
to receive health care benefits.

A nurse in Dr. Smith’s office became addicted to painkillers and with access to patient records she called
in forged prescriptions to a local pharmacist and posed as a family member of the patient when she
picked up the drugs.

Devon was addicted to painkillers, stole and forged prescription forms from his doctor’s office, passed
them at a local pharmacy, and used his health care insurance to pay for the drugs.

Dr. Talbot billed his patients’ health insurance for both the services he actually provided and for services
that were not provided. He falsified his patients’ medical records to reflect office visits and treatments
that never occurred.

Dr. O’Neill received the results of medical testing performed by a diagnostic firm for her interpretation of
the results. She billed the patients’ health insurance as though she performed both the testing and
interpretation of the tests.

Dr. Salazar was employed by a medical center where low-income and indigent patients were recruited to
undergo unnecessary exams. While Dr. Salazar saw few patients, medical records were falsified by a
physician’s assistant to support the billing of insurance programs for procedures that were never
performed.

Consequences
Most health insurance includes specific benefits‚ and health insurance fraud practices such as
overbilling for the type of services received robs consumers of these benefits.
This is why health insurance fraud is such a serious crime. As with all other types of insurance
fraud‚ Pennsylvania considers it a felony. Violators can spend up to seven years in prison and
spend up to $15‚000 in fines. There are also many other associated expenses such as court costs
and legal fees. Plus‚ those found guilty of insurance fraud have the stigmas and limitations of
being a convicted felon to carry with them for life.