Detecting Healthcare Fraud and Abuse in the United States

Abstract

Healthcare fraud involves wide-ranging illegal behaviors. It includes such activities as individual physicians who bill insurance companies or the government for services that were never provided, as well as corporate behavior, such as pharmaceutical companies that falsify clinical tests in order to get unsafe drugs approved for use. Thousands die each year in the United States due to these behaviors, including deaths from incorrectly prescribed medications or from tainted drugs that were approved by the U.S. Food and Drug Administration based upon fraudulent testing and reporting. Thousands of additional patients likely are injured and killed by unnecessary surgeries performed by physicians who want to maximize their reimbursements. The illegal activities also add billions of dollars each year to the total healthcare cost in the U.S. Despite these costs, there is relatively little outrage as a result of the behaviors, largely because they remain hidden from public view. Healthcare fraud, as with almost all white-collar crime, is rarely detected and that prevents the frauds from becoming known to victims, law enforcement, and policy makers, which in turn prevents analysts from compiling a complete picture of the behaviors and prevents policymakers and law enforcement from developing efficient enforcement strategies. Moreover, the lack of detection assures perpetrators that they will get away with their crimes and limits the potential preventative effects of punishment. Lack of detection and reporting has been a particularly strong problem for those trying to control healthcare fraud and abuse in the United States and elsewhere. The enforcement mechanisms that have evolved have been strongly influenced by the difficulties of detecting the illegal behaviors.