HealthCare Fraud 101: A Primer

Topics: Cybersecurity, Financial Crime, Government, Government Fraud, Leadership


Healthcare fraud schemes are a serious problem in the U.S. In fiscal year 2017 alone, the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) recovered $2.6 billion from judgments, settlements and additional impositions in healthcare fraud cases and proceedings. That is a tremendous amount of money, time and resources spent on the detection and prevention of government fraud.

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to healthcare fraud are in the tens of billions of dollars each year.

Identifying Fraudsters

Who exactly are the people and entities that are committing these crimes? Healthcare fraud is committed by healthcare providers, facilities, institutions and even individual patients.

healthcare fraud

Dr. David Botsko, Principal Consultant at David Botsko Consulting

Whether we are talking about providers billing for services not rendered or incorrectly reporting diagnoses or procedures; or Medicaid patients abusing the healthcare system and worsening the nation’s opioid crisis by obtaining and reselling the highly addictive painkillers, the issue of healthcare fraud is receiving attention on a federal, state and local level.

Why does any of this matter? Surely if a doctor wants to overbill her patients to make extra money on the side, that doesn’t directly affect consumers, does it? Of course, it does. Healthcare fraud costs insurers anywhere between $70 billion and $234 billion each year, harming both patients and taxpayers, according to a report issued by the National Conference of State Legislators.

To better understand the mounting problem facing the US today, we turned to Dr. David Botsko, Principal Consultant at David Botsko Consulting, a former federal agent and retired Inspector General for the State of Arizona Medicaid Agency.

In Dr. Botkso’s article, Healthcare Fraud 101, he discusses the differences between fraud, waste and abuse, as well as trends in healthcare fraud and tips for prevention and detection.

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