03/05/2013
2/5/2013
Subject: - a research about healthcare, medicare, medicaid, insurance fraud Middle East forum 2013 Abu Dhabi UAE.
Held on 2/5/2013 at Park Rotana Hotel in Abu Dhabi United Arab Emirates on the 1st and 2nd of May 2013
This is a brief on definitions of fraud as per UAE law, and my legal advises to avoid fraud.
This is our speech regarding fraud I hope to find it useful in forum.
Good afternoon,
I am honored to be in this specific moment among the Elites in the insurance industry.
And thanks god to speak to those remarkable institutions, hospitals, pharmacists, insurance co, personnel.
I am Ezz Eldin, Legal consultant, belonging to
Avocato law Firm in UAE with branch in Egypt.
We had the honor to work with in this field of insurance.
I came to talk about Health Care Fraud, from legal point of view; I shall brief everything for time tight:
Health care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn an interest, or giving any facility like sick leave to non eligible.
So we shall give definition to fraud, forgery and tort
Definition
Difference between fraud and abuse
What’s fraud as to penal code:-
Article 399 of UAE penal code:- Shall be sentenced to detention or to a fine , whoever succeeds in appropriating , for him or for others , movable property , a deed or a signature thereon , cancellation , destruction or amendment thereof through deceitful means or use of false name or capacity , whenever this leads to deceit the victim and have him give away
Should the object of the crime be the property or a deed belonging to the State or tone of the bodies mentioned in Article 5, this shall constitute an aggravating circumstance.
In some cases the fraud comprises forgery, let us define forgery:-
Article 216 of UAE Penal code- ((Forgery))
Forging a written instrument is an alteration of its genuineness, through one of the methods stated hereunder, resulting in sustenance of prejudice, if done with the purpose of using it as a genuine instrument?
Forging methods include:
1 - Effecting a change in an existing written instrument whether by way of addition, deletion or alteration in its words, numbers marks or pictures present in it.
2 - Putting up a forged signature or seal or change a genuine signature, seal or thumb print.
3 - Obtaining by surprise or fraud the signature, seal or thumb print of a person without his knowledge of the contents of the instrument or without his valid consent thereto.
4 - Fabricating a written instrument or imitating it and attributing it to another person.
5 - Filling a paper signed, sealed or thumbs - printed in blank without the consent of the author of the signature, seal or thumb - print.
6 - Impersonating or exchanging the identity in a written instrument made to establish such identity.
7 - Alteration of the truth in a just - made instrument as concerns matters that this instrument is designed to establish.
Article 217 of UAE penal code-
Unless otherwise provided, forging an official written instrument shall be sanctioned by imprisonment for a term not exceeding ten years and the penalty as concerns forging an informal instrument shall be detention.
From the civil side:
2 – Fraud as to Tort law:-
Not to be confused with torte.
A tort is a civil wrong which unfairly causes someone else to suffer loss or harm resulting in legal liability for the person who commits the tortuous act.
Although crimes may be torts, the cause or intention of legal action is not necessarily a crime as the harm may be due to negligence which does not amount to criminal negligence. The equivalent of tort in civil law jurisdictions is delict.
Tort law is different from criminal law in that: (1) torts may be created due to negligent but not intentional and criminal actions and (2) tort lawsuits have a lower burden of proof such as preponderance of evidence rather than beyond a reasonable doubt. Sometimes a plaintiff may prevail in a tort case even if the person who caused the harm was acquitted in an earlier criminal trial. For example, O.J. Simpson was acquitted in criminal court and later found liable for the tort of wrongful death.
Tort law can be split into three categories: negligent torts, intentional torts and strict liability. Negligent torts encompass harm done to people generally through the failure of another to exercise a certain level of care (usually defined as a reasonable standard of care). Accidents are a good example of negligent torts. Intentional torts, on the other hand, refer to harms done to people intentionally by the willful misconduct of another, such as assault, fraud and theft. Strict liability torts, unlike negligence and intentional torts are not concerned with the culpability of the person doing the harm. Instead, strict liability focuses on the act itself: if someone commits a certain act (say, producing a defective product) then that person is responsible for the damages from that act regardless of the level of care exercised or their intentions
Civil Code: - Fraud = Deceit
Article 185 of UAE civil code
Deceit is the act by which one of the parties deceives the other through the use of fraudulent means , in words or other means , inducing him to assent to what he would have never consented to do in the absence of such means .
Article 282 of UAE civil code
The author of any tort, even if not discerning, shall be bound to repair the prejudice.
Article 1033 of UAE civil code:
Abuse or bad faith in insurance
1 - If the insured , in bad faith , conceals a matter or makes a false statement in such a manner as to lessen the importance of the risk insured against , or leads to a change in its object , or if he fraudulently breaches his promise to fulfill an obligation , the insurer is entitled to demand rescission of the contract and be paid all premiums due prior to such demand .
means an act by any person related to the operation of the Health Insurance Scheme which is not in accordance with the ethical standards and requirement of absolute good faith that should apply to all insurance relationships, but does not include an act which amounts to Healthcare Insurance Fraud.
Second Section : - Causes
1 - The “chief motive in all insurance crimes is financial profit. Insurance contracts provide both the insured and the insurer with opportunities for exploitation.
2 - The causes vary, but are usually centered on greed and holes in the fraud fight. Often, those who commit insurance fraud view it as a low-risk, lucrative enterprise. Drug dealers who have entered insurance fraud think it’s safer and more profitable than working street corners. Compared to other crimes, court sentences for insurance fraud can be lenient, so scammers may try to take advantage of the system. Though insurers try to fight fraud, some will pay suspicious claims, since settling such claims is often cheaper than legal action.
3- Historically prevailing attitude in the medical profession is one of “fidelity to patients”. This incentive can lead to fraudulent practices such as billing insurers for treatments that are not covered by the patient’s insurance policy. To do this, physicians often bill for a different service, which is covered by the policy, than that which was rendered.
4- Insurance companies are also susceptible to fraud because false insurance claims can be made to appear like ordinary claims. This allows fraudsters to file claims for actions that never occurred, and so obtain payment with little or no initial cost.
Third: - Fraudulent means: -
Examples of health care fraud include, but are not limited to
1 - Over-prescribing medication and duplicate billing, where the same procedure is paid for twice.
2 - Billing for services, procedures and/or supplies that were not provided.
3- Ordering services that are unnecessary or unwarranted for the purpose of financial gain.
4- The intentional misrepresentation of any of the following for purposes of manipulating the benefits payable:
4.1The nature of services, procedures and/or supplies provided.
4.2The dates on which the services and/or treatments were rendered.
4.3The medical record of service and/or treatment provided.
4.4The condition treated or diagnosis made.
4.5The charges or reimbursement for services, procedures, and/or supplies provided.
4.6 The identity of the provider or the recipient of services, procedures and/or supplies.
4.7 Sick leave granted to non-eligible
6 - Individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit.
7 - Filing duplicate claims for the same service rendered; altering the dates, description of services, or identities of members or providers;
8- Modifying medical records; intentional incorrect reporting of diagnoses or procedures to maximize payment;
9 - Use of unlicensed staff; accepting or giving kickbacks for member referrals;
10- Fraud also involved the creation of false medical histories for the persons in whose names those false claims are filed.
13- Depending on the nature of the fraud, some providers put patients at physical risk solely for the purpose of generating falsified claims.
14 - claims submitted by bogus physicians, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while under suspension, in absence or when license have been revoked or machinery that is not equipped.
15- “up-coding” or “upgrading,” which involve billing for more expensive treatments than those actually provided; providing and subsequently billing for treatments that are not medically necessary; scheduling extra visits for patients; referring patients to another physician when no further treatment is actually necessary; "phantom billing," or billing for services not rendered; and “ganging,” or billing for services to family members or other individuals who are accompanying the patient but who did not personally receive any services.
16- Ghost Patients: The submission of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals provided to a patient who either does not exist or who never received the service or item billed for in the claim.
17- Counterfeit Prescription Drugs
Second: - Fraud committed by the health insurance companies them.
examples of insurance companies intentionally not paying claims and deleting them from their systems, denying and cancelling coverage, and the blatant underpayment to hospitals and physicians beneath what are normal fees for care they provide.
The scams of brokers’
Here are several agents’ scams you should watch for...
1 - Stealing your premiums. An agent pockets insurance premiums instead of sending it to the insurer.
Selling phony insurance policy: - An agent or company rep sells you fake coverage from a phony insurance company. Or the agent sells you bogus coverage using a legitimate company's name, or a name that's similar to a legitimate insurer. You might receive an official-looking policy or proof of insurance that's worthless.
Selling coverage you don't want or need. Maybe the coverage is real, but it's expensive, unnecessary, and your current policy may already cover that risk. Three examples:
• Twisting: An agent may urge you to change policies prematurely by "twisting" the truth about the downside. If you have an illness, injury or other medical condition, for example, will that "affordable" new health policy refuse to cover it because it's a pre-existing condition?
Medical insurance fraud can be prevented by careful and accurate evaluation, recording, and billing of medical treatment by healthcare providers. It is up to healthcare providers, consumers, and insurance firms to work together to prevent this costly and damaging form of fraud.
Tips for Avoiding Health Care Fraud or Health Insurance Fraud:
As to insurance companies:
1- The detection of insurance fraud generally occurs in two steps. The first step is to identify suspicious claims that have a higher possibility of being fraudulent. This can be done by computerized statistical analysis or by referrals from claims adjusters.
2- Additionally, the public can provide tips to insurance companies, law enforcement and other organizations regarding suspected, observed, or admitted insurance fraud perpetrated by other individuals. Regardless of the source, the next step is to refer these claims to investigators for further analysis.
3- Use computers and statistical analysis programs to identify suspicious claims for further investigation. There are two main types of statistical analysis tools used: Supervised and unsupervised. In both cases, suspicious claims are identified by comparing data about the claim to expected values. The main difference between the two methods is how the expected values are derived.
In a supervised method, expected values are obtained by analyzing records of both fraudulent and non-fraudulent claims.
This method has some drawbacks as it requires absolutely certainty that those claims analyzed are actually either fraudulent or non-fraudulent, and because it can only be used to detect types of fraud that have been committed and identified before.
Unsupervised methods of statistical detection, on the other hand, involve detecting claims that are abnormal. Both claims adjusters and computers can also be trained to identify “red flags,” or symptoms that in the past have often been associated with fraudulent claims.
Statistical detection does not prove that claims are fraudulent; it merely identifies suspicious claims that need to be investigated further.
Fraudulent claims can be one of two types. They can be otherwise legitimate claims that are exaggerated or “built up,” or they can be false claims in which the damages claimed never actually occurred. .
Suspicious claims can also be submitted to “special investigative units”, or SIUs, for further investigation. These units generally consist of experienced claims adjusters with special training in investigating fraudulent claims. These investigators look for certain symptoms associated with fraudulent claims, or otherwise look for evidence of falsification of some kind. This evidence can then be used to deny payment of the claims or to prosecute fraudsters if the violation is serious enough.
The substantial level of health care fraud is one of the main reasons why the United States Government Accounting Office has labeled both the Medicare and Medicaid programs “high-risk programs.”
Whistleblowers acting under federal and state false claims acts have proven to be the Government’s best weapon in detecting and pursing healthcare fraud. Whistleblowers are often in the best position to detect fraudulent conduct and to bring it to light by filing a qui tam lawsuit on behalf of the government.
1 – Dedicate an audit and investigation team, with medical backgrounds, who look at suspicious claims and also follow the claims trend from medical service providers for any irregularities in billings.
2- Must prohibits any offer, payment, solicitation or receipt of money, property or remuneration to induce or reward the referral of patients or healthcare services payable by a any health care program.
These improper payments can come in many different forms, including:- referral fees; finder’s fees; productivity bonuses; discounted leases; discounted equipment rentals; research grants; speaker’s fees; excessive compensation; and free or discounted travel or entertainment.
3- Medical Necessity: In order to qualify for payment health care services, treatments, diagnostic tests, medical devices and pharmaceuticals must be medically necessary. Health care providers are required to document the medical necessity of the treatment or services for which they are seeking reimbursement. One common type of fraud has been to submit claims for services, treatments, diagnostic tests, and medical devices that are not medically necessary.
4- Ask for Certification: When physicians, hospitals and other health care providers submit bills health care programs they are required to include a number of important certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all applicable rules and regulations. Additionally, health care companies such as pharmaceutical companies and pharmacy benefits managers that provide products or services to health care programs are required to certify that they are satisfying all obligations under their contracts with the program. One common type of fraud has been to falsify these certifications in order to get a health care claim paid or to obtain additional business.
5- Ask for Improper Financial Interest statement: regulations that prevent physicians and other health care providers from having a direct or indirect financial interest in certain services provided to their patients.
6- Inflating Cost Reports: Hospitals are required to file Cost Reports with insurance co that specify, among other things, information on the hospital’s charges, revenue, profits, and charge to cost ratios. Then use the information it obtains from these reports to determine how much it will pay for this overhead and other costs.
7 – Make -sms -mobile system:-
Like banking transactions, you can arrange a program with any mobile co for advising the patient, insurance co, about the last visit by time, explaining the treatment, medicine prescriptions.
8 – Obligatory to give patients detailed records of treatments, diagnosis received.
Make circulars to Persons:-
Never sign blank insurance claim forms.
Never give blanket authorization to a medical provider to bill for services rendered.
Ask your medical providers what they will charge and what you will be expected to pay out-of-pocket.
Carefully review your insurer’s explanation of the benefits statement. Call your insurer and provider if you have questions.
Give your insurance/Medicare identification only to those who have provided you with medical services.
Keep accurate records of all health care appointments.
Know if your physician ordered equipment for you.
Take and Keep detailed records of treatments you receive. Include all dates, locations, who provided the treatments, what services you received, and what medicine, supplies or equipment were provided.
• Carefully review the billing and summary statements you receive after treatment. Are the treatment dates, doctor name(s), facility locations and medical services the same as you remember? Know what medical equipment and supplies your provider ordered, as well.
• Avoid door-to-door or telephone salespeople who offer you free medical services or equipment.
• Never give strangers your policy number, insurance ID number, Medicare claim number or other info, especially if they offer you cash or free gifts, treatments or equipment.
• Never pay your health premiums in cash, and be wary if the health insurer asks you to pay a full year's premium upfront.
• Back off if the agent offers coverage whose price is 30-50 percent lowers than competitors. Shop around to find out the normal price range.
• Never sign a blank insurance form or give your agent power of attorney to sign an insurance application or buy coverage for you.
• Get a copy of every form you sign.
• Know what your current policy does and doesn't cover. Ask your agent or insurer for a detailed explanation in plain language. Ask pointed questions if you have any doubts about what's in your policy.
-
Impact of fraud: - The price you pay
Coverage drained. Your coverage limits might be drained by worthless and unnecessary treatments.
Financial disaster. Inflated or phantom medical bills can increase your co-payment, beyond your ability to pay. This could force you into collections and damage your credit rating. And if you bought health insurance that ends up completely fake.
False medical record: Your medical record contains false information about illnesses, diseases, injuries or other problems you never had. Your information is available to insurers, so you could be denied health coverage or pay higher premiums because of a trumped-up medical record.
Premiums rise. Your health premiums rise because insurers pass the cost of fraud onto policyholders. High health premiums discourage employers from offering this needed employee benefit.
Personal distress: - You receive bogus or needless treatments that are painful, distressing, can threaten your health — and even kill you.
Legislation
National and local governments, especially after implementing health insurance law, have to recognize insurance fraud as a serious crime, and have to make efforts to punish and prevent this practice.
Establishing fraud bureaus: - is a law enforcement agency where “investigators review fraud reports and begin the prosecution process.
Promulgating new act that should state that whoever attempts or carries out a “scheme or artifice” to “defraud a health care benefit program” will be “fined under this title or imprisoned not more than 10 years, or both.” If this scheme results in bodily injury, the violator may be imprisoned up to 20 years, and if the scheme results in death the violator may be imprisoned for life.
We advise again those who take it easy to violate insurance law, to think over again.
Ezz Eldin Othman
Legal Consultant
Avocato Law Firm
