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Jennifer Dietz, W. Bryan Gamble, John Marchlowska, Bryan T. Wheeler, Fighting Health Care Fraud in Bold and Innovative Ways, Military Medicine, Volume 178, Issue 10, October 2013, Pages 1041–1043, https://doi.org/10.7205/MILMED-D-13-00205
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Health care fraud remains an enormous problem within the United States. In 1993, health care fraud was identified as the number two crime problem in America after violent crime.1 Though the social and political landscape of this nation has changed much since 1993, health care fraud remains a top priority because of the large financial implications to taxpayers. In 2010, Americans spent $2.6 trillion on health care.2 The National Health Care Anti-Fraud Association, a nonprofit collaboration of federal and private health care fraud special investigative units, estimates that between 3% and 10% of health care expenditures are lost to fraud, resulting in approximately $78 to $260 billion stolen from taxpayers on an annual basis.
Health care fraud consists of several different methods or schemes. In almost every case, health care fraud is focused on the money. In the past, health care fraud was almost solely perpetrated by medical providers. However, recent trends are showing that health care fraud perpetrators are now more likely to have little to no medical experience and tend to have criminal backgrounds3 or are part of large pharmaceutical organizations that engage in illegal practices. Last year, GlaxoSmithKline (GSK) admitted to off-label marketing of pharmaceuticals and withholding safety data from the Food and Drug Administration. GSK settled the case with the U.S. Government for $3 billion.4 In May 2013, Ranbaxy USA pleaded guilty to introducing adulterated drugs into U.S. commerce.5 Other current schemes include billing for services not rendered, substituting inferior products and billing for more expensive ones, performing unnecessary procedures to gain greater reimbursement, engaging in kickbacks, and prescribing narcotics for money rather than medical necessity.6 Victims of health care fraud may include the patients, health care workers, insurance companies, and, in the case of federally funded medical benefits plans, the taxpayer.
