Originally posted by: O2bnVegas
Right now one of our two major hospital systems is in negotiations with UHC and about to be dropped from that facility if contract negotiations break down. The hospital is demanding a big increase in pay-back from UHC which UHC is unwilling to meet. If they separate, employees (group insurance plan) and patients under UHC insurance will be without coverage.
Group health insurance premiums and reimbursement are figured for the next year based on a lot of things, including patient age/illness/expenditure last year(s) and predictions for those things going forward. Notice that rates differ by region of the country. People are living longer and having more expensive medications (thanks, pharma), expensive treatments, procedures, on and on.
Insurance fraud occurs when doctors bill (Medicare, Medicaid, insurance companies) for care/procedures not performed. Or a clerk in the office diverts reimbursements to his/her own account. Lots of ways. And of course nobody checking for it...for years.
Social Security fraud occurs when a covered patient dies but the family doesn't report it and continue cashing the checks every month. Direct deposit should have reduced that problem, but depends on where the check is deposited and who has access to the funds.
Fraud due to carelessness and dishonesty. Remember the story of the two sisters who decided to establish a small business selling small hardware items? They were able to get a contract with a Federal agency. They made a nice little income shipping items to the agency. One day the sister who completed the order form accidently entered an incorrect figure for the cost of shipping a small item. Like the shipping cost should have $1.98. Instead it read like $1980.00, typing/computer error. Nobody at the agency caught the error, the ladies were paid $12.87 price of the item, and $1980.00 for the shipping. The sisters were shocked, but decided to try again, increasing the 'shipping' cost figure each time, which went on a long time, nobody at the agency catching it. They profitted millions. They both bought mansions, expensive cars, boats, treated their families and friends to trips to exotic places. Meanwhile the shipping 'cost' still not noticed at the agency. I forget how it was finally discovered, then each sister blaming the other once the indictments started coming in. I think one committed suicide rather than go to prison, something like that. Saw it on the TV show "American Greed", if anyone wants to look it up. Little of that money was clawed back, as I remember, as often happens.
Rant over.
Candy
None of those tales are valid excuses for completely destroying our healthcare system and the government agencies that administer and monitor it. Of course there's fraud and abuse. It's impossible to avoid; it can only be mitigated. Or to put it differently, we can institute a draconian system wherein everything is quintuple-checked and patients routinely die before their paperwork is vetted and they finally receive care. Just like there was very little petty crime in Nazi Germany--if you get my analogy.
If we removed the profit motive from our healthcare system (as in: switched to government-sponsored single-payer care), then this problem would go away.