Electronic Health Information Exchange (HIE) in Reducing Healthcare Fraud

One of the most common fraud essentials in the United States is in the circle of healthcare which is directly affecting taxpayers that in-turn is making funding prospects for health programs and hospitals strenuous. The problem has substantialized into such heights that between 2014–17, investigations led by the United States Federal Government recovered an estimated value of $10 billion only in fraud cases as per reports published by Health-care Finance.

The general public usually has no clue about the fact that most of these healthcare-related cases have direct involvement of programs funded by the government with the turning key residing in the hands of organized criminal groups. Some of these cracked fraudulent cases are so accurate and complex that to escape scrutiny and detections, the help of experienced IT professionals and coders are often called for who help in the duplication of their billing systems, code construction and deciphering and, and various other illegal acts.

United States has implemented HIE and electronic health information exchange to curb such notoriety, eradicate duplicate service schemes, and other frauds including billing errors which will collectively lead to the improvement of maintaining patient records. This article discusses the importance of electronic health records as an elemental key to improving healthcare systems and how EHRs help in the detection of online illegal activities.

Example Frauds in the US Healthcare System

-:Inflated Service Fee

-:Renouncing Co-pays

-:Forging Diagnoses

-:Falsifying Patient Identity

-:Kick-Back Acceptance Referrals


Inflated Service Fee

The most common classifications of healthcare fraud constitute inflated practices of billing. This is more common in private spaces and agencies that provide home healthcare services rather than in hospitals where billing is operated through secure and strict system plans and are aided directly by government agencies with frequent audits and scrutiny.

Fees categorization is subjective and most medical institutes do not provide clear insights on the same because treatments and procedures vary vastly among patients. There is no confirmed ‘flat rate’ available to patients until their treatment estimation is provided by their insurance company for particular services. This is a big window of opportunity for fraud healthcare service providers to magnify the total billing amount by adding several unutilized services or by increasing the total billing amount before the insurance company claiming an amount more than that was billed in actuality.

Healthcare services in the United States run under a code that administers billing limits to medical procedures and care. In technical terms, this is known as up-coding that allows a change in a patient’s documentation or diagnosis that legally allows them to add medical care costs even though they were not implemented.

Renouncing Co-pays that Charge Healthcare and Insurance Providers

This act of fraudulence is also very common in every sector of healthcare from diagnostic centers to dental services, testing or laboratory facilities to private practitioners. Sometimes, waiving of co-pays can be justified in cases where the patient party is not resourceful enough to pay even the minimum medical charges. This is sometimes looked after by the doctors themselves where they attempt to roll-in the overall costs to the insurance company by increasing the rates of the services under the billing list. Medicaid has provisions directed at medical practitioners to waive copayments for patients under economic hardships. But several criterions must be complied with for a patient to be eligible for the claim. However, this provision does not provide long-term financial support for economically solvent patients.

Forging Diagnoses and Falsifying Patient Identity

Even general medical tests have become quite expensive. But if a patient does not require tests before the initiation of his or her treatment, the healthcare provider has the pass to fake diagnoses to get the patient eligible for tests that are included in their insurance listings. Misinterpreting any diagnosis classifies as fraudulent irrespective of what circumstances it may lead to but it is quite common.

Fraudulence in healthcare occurs within the family circle as well. Identity theft is another major problem here where the specifications and credentials of a deceased patient are used by a member of the family attempting to ingress medical insurance coverage. International hackers are always on the lookout to garner patient records, identity documents, and reports associated with the same. Confidential patient information is often sold at a cheap rate of $10-$15 dollars per identity which further assists people to exploit medical fraud.

Kick-Back Acceptance Referrals

Paying for referrals in the scope of health-care is explicitly illegal. Misinterpretation of diagnoses that were not implemented as part of the tests is often directed to gain extra profit from the billing. This kind of fraudulent activity is most common in retirement care wings and facilities where patients are tied to supplemental insurance or Medicaid.

Working Principle of HIE in the Detecting Fraud

HIE and EHR help put together a precise patient record that can be accessed by the patients as well as respective authorized physicians and doctors. Hypothetically and logistically, if HIE is fully implemented across the entirety of the American health-care system, the process will be a lot easier to maintain and allow for better patient care.

HIE will also help government agencies to easily detect fraud bills. Rather than completely relying on paperwork regarding billing and services, the virtual system will be far more user-friendly with strict privacy encryption. However, apart from HIE, the federal government already has tools at their disposal that helps in the detection of notorious fraudulent acts and provide financial aid for those who were subject to healthcare corruption.

EHRs have reduced various discrepancies in the medical sector by deliberately incorporating fraud billing as a beta test. The money that will be retrieved through such aids can then be utilized in the betterment of various healthcare services and in improving treatments while cutting down costs for the insuring company and administrators looking after the medical programs. The efficiency and cost-effectiveness that comes with this system will help patients with better diagnosis, treatment, and care.


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