September 1, 2021 0 Comments Health & Fitness

Fraud In The Healthcare System – Gregory Pimstone

According to the 2018 National Money Laundering Risk Assessment, healthcare fraud consists of 35% of all illegal proceeds laundered in the United States. Fraud in the healthcare systems manifests in legal transactions with medical professions or doctors to manipulate the internal protocols to favor their concerns in a given area.

Gregory’s view on reimbursement

Gregory Pimstone suggests to fight fraud in the medical field, prices for emergency-based care should be set depending on the benchmarks of the given situation. He suggests that a rational system should direct the legislature to hear a case based on the testimonies from all stakeholders to determine whether a claimant can be given the defined price or another amount.  Although, the Biden administration has come up with new legislation a variety of factors that a trier of a fact may consider in determining a reasonable payment for services offered, Pimstone argues that the new legislation does not help fix the problem as it does not provide clear and defined directions to courts, providers, and carriers.

Fraudulent behaviors in reimbursement of emergency care services.

Some PPO health insurance plans offer out-of-network services allowance, but the client will be required to pay a non-negotiable amount with the insurance company. This plan enables the out-of-network service providers to demand any amount they want.

The removal of medical underwriting is also considered as a loophole to fraudulent schemes. For instance, although it was aimed at making easier access for patients with pre-existing conditions to explore affordable coverage, it has a chance of giving way to dishonest opportunists. For example, Out-of-network substance abuse treatment providers paid recruiters to find individuals who were struggling with addiction. The service providers would then find private insurance offering out-of-network benefits and enroll these patients in the program. The facilities or recruiters would then cover the premium costs, outlining the cost-sharing obligations, therefore, directing the patient towards out-of-network.

Worsen the Pandemic

Other than the above fraudulent scheme, healthcare that is funded federally is highly targeted by fraudsters. In this case service provider’s payment of a beneficiary’s premium or waiver of coinsurance ultimately raises the cost to the Medicare program. This is manifested in the federal anti-kickbacks and beneficiaries being prohibited from been given inducements. These fraudulent schemes are still present even with the pandemic and have enriched many dishonestly while costing healthcare consumers hence making the pandemic effects more devastating.


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