Date of Award
Thesis (Restricted access)
Master of Science (MS)
Healthcare fraud is an expensive, pervasive problem both domestically and globally. It can exist in many forms and be executed by nearly anybody. This paper will focus on healthcare fraud schemes executed by physicians against payers. These payers include private insurers and government entities, including Medicare and Medicaid. Three specific methods by which physicians execute such fraud will be discussed, which are upcoding, phantom billing, and recommending medically unnecessary procedures. As these methods are discussed, it is important to note how they fit into the category of fraud. Each method involves the payers and patients relying on the physicians, the physicians intentionally misrepresenting material information, and damages being direct results of the physicians' misrepresentations. This paper will also discuss three current strategies for effectively and efficiently combatting healthcare fraud committed by physicians. This will include a strong focus on the strength of data collection and analytics as well as educating patients. A discussion of measures to take going forward will be present with an emphasis on centralizing data, encouraging patients to participate in antifraud activities, and improving peer reviews. Some of my own takeaways from researching this will also be briefly discussed.
Toldt, Justin, "Fraud by Physicians" (2017). Economic Crime Forensics Capstones. 21.