Better Education and Technical Know-how Can Combat the High Cost of Fraud

If Legal Nurse Consultants had a patron saint, it might be the 4th Century (BC) Greek philosopher, Diogenes, well known for his quest to find an honest man in the marketplace.  He used a lantern to shed light and dogs to help him tenaciously sniff out the truth.  In fact, his school of philosophy, Cynicism, got its name from the Greek word for doglike – kynikos.

If Legal Nurse Consultants had a patron saint, it might be the 4th Century (BC) Greek philosopher, Diogenes, well known for his quest to find an honest man in the marketplace. He used a lantern to shed light and dogs to help him tenaciously sniff out the truth. In fact, his school of philosophy, Cynicism, got its name from the Greek word for doglike – kynikos.

The FBI estimates that healthcare fraud costs the country an estimated $80 billion a year!  It’s the Number One factor responsible for the country’s astronomical increases in healthcare costs.

Fraud defined

The National Health Care Anti-Fraud Association says that healthcare fraud is “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.”

Fraud and abuse can come in many forms.  It can include acts (and inaction) committed by providers as well as patients.  Providers may, for example…

  • Bill for services not provided
  • Duplicate submission of claim for same service,
  • Misrepresent the service provided, and
  • Bill for a covered service when the service provided was actually not covered

Plan Members may abuse the system by…

  • Doctor shopping
  • Filing for reimbursement on services or medications not received or performed
  • Falsification of information or injury
  • Forging or selling prescription drugs, and
  • Using transportation benefit for non-medical related business

Why is healthcare today so vulnerable to fraud

One reason is that medicine has become much more complex, and the doctor-patient relationship has changed.  For instance, a patient nowadays might be under the care of multiple providers, and each provider might not have a clear picture of the patient’s plan of care.

Another reason the system is vulnerable to fraud relates to constant changes in billing and coverage.  Terms and conditions of reimbursement often change, too, and they’re highly technical and arcane.  Moreover, the urge – whether cultural or economic – for quick fixes creates opportunities for fraud.

What’s being done about it?

Various public and private-sector anti-fraud organizations have formed.  Through education and working with lawmakers and regulators, they’ve made progress preventing fraud and reducing its cost to the system.  The legal nurse consultant is another resource to which many fraud investigators have turned for the technical knowledge and experience it often takes to spot a fraudulent medical claim.


Jordan Ilderton, RN, BSN is a Legal Nurse Consultant with MKC Medical Management.  Contact Jordan at jordan@mkcmedicalmanagement.com.