Health insurance fraud and its impact on the health care system Wherever it’s found, fraud and corruption cost more than just the money some get away with. Like a stone dropped into a pond, the effects of fraud and corruption in a health care system can send ripples outwards, nudging everything in its wake from costs and resources in the sector. As mentioned in our earlier article on insurance fraud, as well as in the trends discussion of our 2017 report on the Cost of International Health Insurance, the issues of corruption and fraudulent claims remains some of the biggest challenges the sector continues to face. This week, Pacific Prime discusses what health system insurance fraud looks like, and what it does to the sector.

In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. It is an undisputed reality that some of these health insurance claims are fraudulent. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag. The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.

The most common types of fraud committed by dishonest providers include:

• Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
• Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
• Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
• Unbundling - billing each step of a procedure as if it were a separate procedure.
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
• Accepting kickbacks for patient referrals.
• Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship").

The EHFCN Waste Typology Matrix enables to describe precisely the issues of mistakes, misuse, fraud and corruptions in Health  and the type of situation  (invoicing rule violated, needlessly expensive or unnecessary service).

The EWTM is a good basic document. Thanks to its analytical method and its nuanced definitions the communication will improve and the Inspection Services in charge of the struggle against waste, fraud and corruption in the Healthcare sector will be able to set better targeted aims. No doubt that it will be assessed and improved in the future but at least it exists and it contributes to the continuous improvement of the best practices guidelines for the Inspection Services.

SWI swissinfo (16.06.2018) One hundred years ago, the Swiss Accident Insurance Fund (SUVA) was established. While the focus used to be occupational accidents and diseases, leisure accidents have become more common. =

The Journal (05.06.2018)  Regina Doherty has ruled out cutting child benefit for higher earners saying she believes in the universality of the payment.

Nippon (17.06.2018) One of the final sessions of the first Asian Impact Dialogue on Ageing and Demographic Change in Asia was the Road Map to the Future workshop. Kogiso Mari, director of the Sasakawa Peace Foundation in Tokyo, led attendees in reflecting on the key take-away lessons gained from the days of discussion in Singapore, with a focus on how elder care and future care forums can be improved.

HelpAge International (June 2018) Starting this week, more than half a million older women and men in Kenya are receiving their first ever pensions. Under the new Government-funded Inua Jamii 70 and Above universal social pension, launched by President Uhuru Kenyatta on Saturday 2 June, all Kenyans over 70 will receive 2,000 shillings (just under US$20) per month.

Comparative Migration Studies   (June 2018) In Belgium, for instance, there are officially 21.084 Latin American registered. 60% of them are women. Colombians (around 5000) and Peruvians (around 2000) are among the most numerous groups and are also characterized by an over-representation of women (DGSIE, 2010), 2- MDW is the acronym for Migrant Domestic Worker; 3-The French word “Madame” used during the interview conducted in Spanish refers to her employer.

Le Monde (14.06.2018) Un amendement dans la loi Pénicaud 2 va créer des chartes et des droits pour améliorer la couverture sociale des personnes employées par des plates-formes numériques.

Ilo working paper (05.06.2018) Social protection programmes require processing significant data amounts, including often-sensitive information such as household assets, health status and physical or intellectual disabilities. Now more than ever, it is critical to address issues of privacy and data security in social protection programme design, implementation and evaluation.

RCF (13.06.2018) Treize départements français ancrés à gauche se sont portés volontaires pour expérimenter le revenu de base, une idée qui remonte à la précédente campagne pour la présidentielle.

Reuters (03.06.2018) Italy’s new anti-establishment government will change the labor reform introduced by the previous administration, Labour and Industry Minister Luigi di Maio said

Weekly News (11.06.2018) A manual is being created for the National Insurance Board (NIB) which will provide clear processes and principles for governing the institution.

Philippine Information Agency (11.06.2018) The Social Security System is currently making big steps to improve social security and retirement benefits for its members  and in  improving the financial viability of the institution while enjoining   members  to regularly pay their contributions  as investment  for their future

Le Temps (12.06.2018)  Le chômage de longue durée touche essentiellement les plus de 50 ans, qui se sentent souvent discriminés à l’embauche. Seule une minorité de Suisses travaille jusqu’à l’âge de la retraite alors qu’il faudrait plus de cotisants pour assurer la pérennité des assurances sociales

Les Echos (12.06.2018) La prévision de déficit pour 2018 de cette branche de la Sécurité sociale a été ramenée à 500 millions d'euros. Le régime général et le Fonds de solidarité vieillesse frôlent également l'équilibre grâce à des cotisations sociales plus fortes que prévu

developmentpathways.co.uk (30.05.2018) Indonesia is one of the few countries in South-East Asia not to have a social pension. The only pensions available are financed from social insurance and, in the main, are received by former civil servants. In fact, only around 15 per cent of older people can currently access a pension, and yet more than 20 million people are aged 60 years and over, the majority being women.

economist.com (31.05.2018) Safety-nets, in one form or another, have proliferated across Africa in recent years

rtve.es (04.06.2018) Un tribunal considera "falsos autónomos" a los repartidores de Deliveroo y condena a la empresa por despido improcedente.

The New York Times (07.06.2018) You can see the gig economy everywhere but in the statistics. For years, economists, pundits and policymakers have grappled with the rise of Uber, the growth of temporary work and the fissuring of the relationship between companies and their workers. Optimists cheered the flexibility offered by the freelance life. Pessimists fretted about the disappearance of traditional jobs, with the benefits and legal protections they provided. That debate has played out largely in the absence of solid data.

The location of offices of public employment services matters. It can bring jobseekers and vacancies closer together to accelerate the matching process and make the best use of resources. In the case of Brazil, financial consolidation calls for better job placement and better spending of public resources. - See more at: https://publications.iadb.org/handle/11319/8879#sthash.BqkbKMmC.dpuf

information-age (06.06.2018) GSMA and W20 have advanced a series of proposals ahead of G20 Summit in the hope of closing the digital gender gap.

March 2018 - Brussels, Belgium - The main topics that will be addressed are the new forms of work and their impact on social security schemes as well as the need to achieve adequate coverage and levels of benefits and at the same time guarantee financial sustainability.

Süddeutsche (31.05.2018) Maschinen sind dazu da, Arbeit zu erleichtern - und nicht, Arbeit wegzunehmen. Die Angst vor ihnen ist so unbegründet wie schon bei der Erfindung des Autos.