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ฟลอร์เฟื่องฟ้า : ดนุพล แก้วกาญจน์

 

                 หาเวลาไปพักผ่อนกันบ้าง …

 

 


 


 


 


 


 


 


 


 




 

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  844. Currently, wellbeing treatment fraud is all around the news.
    There undoubtedly is fraud in health care. The same is genuine for every organization or endeavor touched
    by human hands, e.g. banking, credit score,
    coverage, politics, and so forth. There is
    no problem that health and fitness care suppliers who abuse their posture and our have faith in to
    steal are a challenge. So are individuals from other professions who do the
    similar.

    Why does overall health care fraud seem to get the ‘lions-share’ of awareness?
    Could it be that it is the ideal car to travel agendas for divergent groups exactly where taxpayers, health care shoppers and overall health
    treatment companies are dupes in a health care fraud shell-activity operated with ‘sleight-of-hand’ precision?

    Just take a nearer seem and a single finds this is
    no video game-of-prospect. Taxpayers, shoppers and companies normally shed mainly because the
    dilemma with wellbeing treatment fraud is not just the
    fraud, but it is that our governing administration and insurers
    use the fraud challenge to additional agendas though at the identical time fail to be accountable and take obligation for a fraud trouble they aid and permit to prosper.

    one.Astronomical Charge Estimates

    What improved way to report on fraud then to tout fraud price estimates,
    e.g.

    – “Fraud perpetrated from both equally community and non-public wellbeing designs charges among $seventy two and $220 billion yearly, raising the value of health-related treatment and overall health insurance and undermining public have faith in in our well being care system… It is no longer a top secret that fraud represents a single of the swiftest developing and most pricey sorts of crime in The usa today… We pay these expenditures as taxpayers and via better wellness insurance coverage rates… We will have to be proactive in combating health treatment fraud and abuse… We must also ensure that legislation enforcement has the tools that it needs to deter, detect, and punish well being treatment fraud.” [Senator Ted Kaufman (D-DE), ten/28/09 press launch]

    – The Typical Accounting Business (GAO) estimates that fraud in health care ranges from $60
    billion to $600 billion for each year – or anywhere
    involving three% and 10% of the $two trillion wellbeing care funds.

    [Wellness Care Finance Information reviews, ten/two/09] The GAO is
    the investigative arm of Congress.

    – The Countrywide Overall health Care Anti-Fraud Affiliation (NHCAA) stories in excess of $54 billion is stolen each individual year in ripoffs designed to
    adhere us and our insurance plan firms with fraudulent and
    illegal health care expenses. [NHCAA, net-site] NHCAA was developed and is funded by health and fitness insurance firms.

    Sadly, the dependability of the purported estimates is dubious
    at most effective. Insurers, condition and federal companies,
    and some others may assemble fraud details connected to their own missions, exactly where the kind, top quality and volume of
    data compiled varies commonly. David Hyman, professor of Legislation, College of Maryland,
    tells us that the greatly-disseminated estimates of the incidence of
    health and fitness treatment fraud and abuse (assumed to be 10% of full shelling out) lacks
    any empirical basis at all, the little we
    do know about wellness care fraud and abuse is dwarfed by what we do not know and what we know that
    is not so. [The Cato Journal, three/22/02]

    two.Well being Treatment Criteria

    The regulations & principles governing health treatment – fluctuate from condition to condition and from payor to payor – are substantial and really complicated for providers and other people to comprehend as they
    are written in legalese and not basic communicate.

    Vendors use precise codes to report circumstances handled (ICD-9) and companies rendered
    (CPT-4 and HCPCS). These codes are used when trying to find compensation from payors
    for companies rendered to clients. Though produced to universally implement to aid correct reporting to mirror providers’ companies,
    quite a few insurers instruct suppliers to report codes based mostly on what the insurer’s
    computer system modifying applications identify – not on what the provider rendered.
    Additional, practice developing consultants instruct providers on what codes to report to get compensated – in some circumstances codes that
    do not properly reflect the provider’s services.

    People know what products and services they acquire from their doctor or other supplier but may well
    not have a clue as to what those people billing codes or
    company descriptors signify on clarification of advantages obtained
    from insurers. This deficiency of knowledge may perhaps result in buyers relocating on without the need of
    getting clarification of what the codes indicate, or
    could outcome in some believing they were improperly billed.

    The multitude of insurance plan options available these days, with different concentrations of protection, advertisement a wild card
    to the equation when expert services are denied for non-protection – especially if it
    is Medicare that denotes non-coated products and services as not
    medically required.

    three.Proactively addressing the well being care fraud dilemma

    The governing administration and insurers do quite minimal to proactively address the issue with tangible things to
    do that will final result in detecting inappropriate statements just before they are paid out.

    In fact, payors of well being treatment promises proclaim to operate
    a payment process based on have confidence in that providers monthly bill accurately for providers rendered, as they can not critique just about every assert right before payment is manufactured since
    the reimbursement program would shut down.

    They claim to use innovative laptop plans to appear for errors and designs in statements, have increased pre-
    and article-payment audits of picked providers to detect
    fraud, and have designed consortiums and undertaking forces
    consisting of law enforcers and insurance investigators
    to review the challenge and share fraud facts. On the other hand, this activity, for the most section, is working
    with activity immediately after the claim is paid and has little bearing on the
    proactive detection of fraud.

    4.Exorcise health and fitness care fraud with the generation of new
    legal guidelines

    The government’s stories on the fraud issue are posted in earnest in conjunction with efforts to reform our health and fitness treatment system, and our experience reveals us that it finally results in the governing administration introducing and enacting new guidelines – presuming new regulations will consequence in much more fraud detected,
    investigated and prosecuted – without the need of establishing how new legal guidelines
    will execute this far more effectively than present legislation that were not utilized to their comprehensive prospective.

    With this kind of attempts in 1996, we bought the Overall
    health Coverage Portability and Accountability Act (HIPAA).
    It was enacted by Congress to handle insurance coverage portability and accountability for patient privacy and wellness treatment fraud and abuse.
    HIPAA purportedly was to equip federal law enforcers and
    prosecutors with the instruments to assault
    fraud, and resulted in the creation of a variety of new health
    treatment fraud statutes, such as: Wellbeing Care Fraud, Theft
    or Embezzlement in Overall health Treatment, Obstructing Legal Investigation of Well being Treatment, and Untrue
    Statements Relating to Wellbeing Care Fraud Matters.

    In 2009, the Health and fitness Care Fraud Enforcement Act appeared on the scene.
    This act has not long ago been launched by Congress with promises that
    it will construct on fraud prevention efforts and fortify the governments’ ability
    to examine and prosecute waste, fraud and abuse in the two governing administration and personal health insurance by sentencing raises redefining well being care fraud offense improving upon whistleblower promises making frequent-perception psychological point out
    need for well being care fraud offenses and expanding funding in federal antifraud shelling out.

    Undoubtedly, law enforcers and prosecutors
    Ought to have the resources to efficiently do their jobs.

    Nevertheless, these actions by itself, with no inclusion of
    some tangible and sizeable right before-the-assert-is-compensated steps, will have tiny affect on lessening the incidence of the issue.

    What’s one particular person’s fraud (insurance company alleging medically unnecessary providers) is one more person’s savior
    (service provider administering assessments
    to defend from prospective lawsuits from lawful sharks).
    Is tort reform a possibility from individuals pushing for well
    being care reform? Regretably, it is not! Help
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    If Congress definitely needs to use its legislative powers
    to make a change on the fraud challenge they must assume outside
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    Concentrate on some front-conclude action that deals with addressing the
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    are illustrative of methods that could be taken in an effort and hard
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    -Desire all payors and vendors, suppliers and some others only use approved
    coding programs, exactly where the codes are clearly defined for ALL to
    know and fully grasp what the unique code implies.

    Prohibit everyone from deviating from the defined which means when reporting products
    and services rendered (suppliers, suppliers) and adjudicating promises for payment (payors and other folks).

    Make violations a rigorous liability problem.

    -Have to have that all submitted claims to public and personal insurers be signed or annotated in some trend by the individual (or suitable consultant)
    affirming they been given the described and billed companies.

    If these types of affirmation is not existing
    claim isn’t compensated. If the declare is later identified
    to be problematic investigators have the skill to talk with equally the service provider and the affected individual…

    -Involve that all statements-handlers (specially if
    they have authority to shell out promises),
    consultants retained by insurers to guide on adjudicating statements, and fraud investigators be qualified by a national accrediting organization below the purview of
    the federal government to exhibit that they have the requisite understanding for recognizing wellbeing care fraud, and
    the awareness to detect and look into the fraud in health and fitness care promises.
    If these kinds of accreditation is not obtained, then neither
    the personnel nor the guide would be permitted to touch
    a wellbeing care declare or investigate suspected wellness care
    fraud.

    -PROHIBIT community and non-public payors from asserting fraud on promises beforehand paid out where by it is established that
    the payor realized or ought to have known the assert was improper and
    should not have been paid out. And, in all those conditions wherever fraud is recognized in paid out statements any monies gathered from companies and suppliers for overpayments be deposited into a countrywide account to
    fund many fraud and abuse schooling plans for consumers, insurers, law enforcers, prosecutors, legislators and other people fund front-line investigators for condition health
    and fitness care regulatory boards to look into fraud in their respective jurisdictions as
    very well as funding other health and fitness treatment associated activity.

    -PROHIBIT insurers from increasing premiums of policyholders centered on estimates of the occurrence of fraud.

    Require insurers to set up a factual basis for purported losses attributed to fraud coupled with exhibiting tangible evidence of their initiatives to detect and examine fraud, as effectively as not
    having to pay fraudulent promises.

    5.Insurers are victims of wellbeing treatment fraud

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