Fraudulent Activity in Healthcare

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Table of Contents

Introduction
Staff Levels, Particularly Skilled Nursing and Other Health Professionals
Human Resource Management and Development
Technology Advancements
Organizational Restructuring
Financial Solvency
Development of Community Health Support Services
Communication with Key Stakeholders in the Community, Government
Conclusion
References

Introduction

Since the beginning of the COVID-19 pandemic, there has been a noticeable increase in fraudulent activity involving healthcare insurance. Due to this, several different insurance firms have been forced to endure financial losses. The two proposals related to the utilization of insurance will have a favorable impact on the healthcare industry in several aspects outlined in this article. Included in the list of recommendations is a provision to guarantee that health insurance will pay for only legally defensible forms of medical care, as suggested by Gupta and colleagues (2021). The second suggestion emphasizes raising knowledge regarding the various forms of medical insurance fraud.

Staff Levels, Particularly Skilled Nursing and Other Health Professionals

The health insurance policy will ensure that it only pays for actual medical expenses. Due to this, the staff will not engage with the patients in fraudulent activities that could result in losses experienced by the healthcare facility and the insurance company (Salah et al., 2020). Understanding the most prevalent types of fraud in the healthcare insurance sector will guarantee that medical professionals uphold the highest levels of ethics and professionalism. They will present patients with all pertinent information on their prescribed treatment. It will ensure that no legal proceedings are taken against the personnel for indulging in fraudulent activities, which, in the worst case, results in a misdiagnosis, ultimately resulting in the patient’s death.

Human Resource Management and Development

It is possible for there to be insurance fraud committed within the hospital, which could result in damaging the reputation of the healthcare facility. As a result, several insurance companies’ relationships with the hospital are severed (Thaifur et al., 2021). The incident, therefore, leads to a relatively small number of patients who use the facility’s services, and the facility’s inability to satisfy those patients’ requirements, the facility will end up incurring losses financially. Regardless of whether or not the fraudulent behavior that occurred within the organization is identified, the human resource department is responsible for any fraudulent activity that took place within the company. As a direct consequence of the anticipated recommendations, the department will be in a position to recognize and address instances of fraudulent activity. They will be able to do so before the matter worsens and the facility’s reputation is damaged.

Technology Advancements

Since the COVID-19 outbreak first started, healthcare fraud has been a significant cause for concern for medical facilities all around the world. Even though institutions involved with social security always seek to streamline procedures, this is the case. With more advanced analytics and artificial intelligence, fraud can be detected and monitored more effectively and efficiently (Mackey et al., 2020). The implementation of the suggested principles will have a positive impact on the technology that is already in place within the healthcare institution to identify instances of fraudulent activity. As a direct result of the recommendations, modifications will be made to how billing codes, telemedicine, and prescription practices are carried out. Given these modifications, healthcare systems will now be able to successfully personalize the administration of treatment procedures to each patient.

Organizational Restructuring

It is necessary to conduct an assessment as part of the organizational restructuring process to identify areas of competency that need improvement and potential dangers to which the healthcare institution may be exposed. Insurance fraud in the healthcare industry is a possible danger that, if not addressed swiftly, will severely impact the organization (Mackey et al., 2020). As a result, the recommendations are critical for evaluating and developing the necessary changes to the organizational structure required to deal with the fraudulent acts that would harm the firm. The specific recommendations focus on the measures that should address the issue. As a consequence, the reorganization will protect the organization’s interests while also enhancing the quality of service provided to its patients.

Financial Solvency

A healthcare institution, its employees, patients, or an insurance company representative can all be guilty of committing healthcare insurance fraud, which is defined as the intentional use of deceit to obtain financial gain. The vice led to financial losses being sustained by an insurance company, which, when discovered, led to financial losses being sustained by the healthcare institution, which, in turn, led to the facility’s eventual financial collapse. Given the negative influence that the vice has on all parties involved, the guidelines are critical for ensuring that the facility’s stakeholders are aware of the vice’s ramifications and the disastrous repercussions it causes. Since the insurance provider will foot the bill for any claims that are filed, the increased visibility that the proposals will bring about will benefit the facility’s ability to remain financially solvent. Consequently, the institution will have sufficient cash to maintain its day-to-day activities.

Development of Community Health Support Services

Designing and modifying a procedure that considers the social and health context to deliver community health support services is vital. It provides aid in managing care transitions for vulnerable people, increasing the likelihood that they will receive healthcare services if they ever require them. Due to the financial losses incurred by insurance companies and health institutions due to healthcare insurance fraud, it is increasingly difficult to support the most vulnerable sections of society (Atnafu et al., 2018). As a result, insurance companies must charge their clients more premiums to cover the rising number of claims filed by people affected. They cannot access medical care whenever required because they cannot afford the costly premiums. As a result of the proposals, claims will be able to be legitimate, and the number of incidents of fraud will decrease dramatically. Consequently, the most vulnerable people in society will have access to medical care whenever necessary.

Communication with Key Stakeholders in the Community, Government

The healthcare facility’s reputation among the stakeholders with whom it interacts must be maintained at all costs; therefore, the proposals that have been put out are of the utmost importance. Given this, fraudulent activity at the facility shall reduce drastically, and its reputation and ratings will not suffer in any way (Gupta et al., 2020). As a result, the organization’s commitment to ethical practices will improve communication with its many stakeholders. The only way that progress can be guaranteed is through the widespread distribution of necessary information across all parties involved, which can be accomplished through establishing efficient communication with the relevant stakeholders. Consequently, the ideas are essential for ensuring that the appropriate forms of communication are being carried out effectively within the structure.

Conclusion

In light of what has been discussed, the suggestions made will positively affect how the healthcare institution deals with instances of healthcare fraud. Since the vice’s negative impacts are detrimental to all interested stakeholders, they should be prevented at all levels. Therefore, it is vital to be aware of the fraudulent activities that affect healthcare insurance to enable the relevant stakeholders to take appropriate measures to minimize the negative repercussions of these activities.

References

Atnafu, D. D., Tilahun, H., & Alemu, Y. M. (2018). Community-based health insurance and healthcare service utilisation, north-west, Ethiopia: A comparative, cross-sectional study. BMJ Open, 8(8).

Gupta, R. Y., Mudigonda, S. S., Baruah, P. K., & Kandala, P. K. (2020). Implementation of correlation and regression models for health insurance fraud in COVID-19 environment using actuarial and Data Science Techniques. International Journal of Recent Technology and Engineering (IJRTE), 9(3), 699–706.

Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating health care fraud and abuse: Conceptualization and prototyping study of a blockchain antifraud framework. Journal of Medical Internet Research, 22(9).

Salah, D., Ahmed, M. H., & ElDahshan, K. (2020). Blockchain applications in Human Resources Management. Proceedings of the Evaluation and Assessment in Software Engineering.

Thaifur, A. Y., Maidin, M. A., Sidin, A. I., & Razak, A. (2021). How to detect healthcare fraud? “A systematic review.” Gaceta Sanitaria, 35.

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