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What is Healthcare Fraud

Chapter 21
Encyclopedia of Criminal Activities and the Deep Web
An intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party Healthcare fraud refers to illegal acts of misrepresentation and false claims in order to receive undue financial or healthcare advantages. Health care fraud accounts for between 2 and 10% of wasted health resources globally. The World Health Organization cites healthcare-related fraud as one of 10 leading causes of inefficiency in health systems. Web-based healthcare fraud is a major challenge, especially when signatories to health organizations’ accounts siphon money into private bank accounts. Regular audits and electronic monitoring systems such as e-claims management services help to monitor and prevent healthcare fraud.
Published in Chapter:
Whistleblowing to Expose Criminal Activity in the Health Sector
Niyi Awofeso (School of Health and Environmental Studies, Hamdan Bin Mohammed Smart University, UAE)
Copyright: © 2020 |Pages: 16
DOI: 10.4018/978-1-5225-9715-5.ch021
Abstract
A whistleblower is an employee who alleges wrongdoing by his or her employer (or any organization) of the sort that violates public law or tends to adversely affect the public or at least some members of the concerned organization. The World Health Organization cites healthcare-related fraud as one of 10 leading causes of inefficiency in health systems. Despite the potential of whistleblowing to reduce healthcare fraud and unearth criminal negligence with respect to patient safety, it remains a highly controversial approach for exposing criminal activity and improving patient safety in the health sector. This chapter discusses the main aspects of healthcare fraud as well as the potential of whistleblowing to address such widespread health system deficiencies, particularly those cybersecurity-related. The author favours internal whistleblowing for criminal misdeeds in the health sector as a first resort. Veracity of whistleblowing allegations should not be taken for granted, and due process must be accorded all individuals accused of criminal negligence or fraud.
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