Tuesday, March 20, 2012

303 years Prison Sentence for Medical fraud ?



There are times, when Human Rights activists spring up calling it punishments cruel and inhuman.  While it is to be admitted that every human being is to be treated with dignity and not subject to any form of cruelty – why not the same yardstick is applied to victims who are battered by criminal acts ?  Why no such plea or fight for justice for old people who are killed or maimed cruelly for money or estate ?

Insurance frauds is a big chapter.. there are varied ways by which Insurers are cheated and money is siphoned from the Insurers by false, bogus, inflated claims.  In the United States, Medicare fraud is a general term that refers to an individual or corporation that seeks to collect Medicare health care reimbursement under false pretenses.   The commonality of all frauds is to collect money from the medicare programme or Insurance scheme.   The looters wear many hats and not infrequently, submit inaccurate bills. It could range from falsely creating the hospital or hospital records when there was no hospitalization or treatment to creating or exaggerating bills by altering, forging with or without connivance.  Some would try to justify such acts speaking of the higher rates being charged by the service providers.  Even where all records are digitalized and accessible, people would try to manipulate by entering inaccurate codes or sections to derive illegitimate benefit.  Where most records are maintained manually and away from Public access, manipulation becomes easier.  Fraudulent billing practices and exaggerated claims eventually end up raising the claim costs and in turn lead to increased premium. But individuals may not bother much as long one can still benefit at the cost of other and would not care whether it is ethical, legal and righteous.  There could even be instances of wrong or forged prescriptions to get the benefit of high costing medicines.

Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.  Fraud can be committed by individual policy holders and service providers in various forms.  The frauds perpetrated  by policy holders would include claiming for those who are not covered, claiming for pre-existing, claiming for pre-incurred, altering records, international failure to report other coverage or other benefits, and more.  Frauds committed by the Service providers could be in the nature of  bogus physicians, billing for services not rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while under suspension or when license have been revoked. The list is never complete and there could be more ways of committing fraud !!


Have read about ‘Rh disease (also known as Rhesus isoimmunisation disease) – i.e.,  Rhesus incompatibility.  In newborns, it is one of the causes of hemolytic disease of the newborn (HDN). The disease ranges from mild to severe, and typically occurs  in some second or subsequent pregnancies of Rh negative women where the fetus's father is Rh positive,leading to a Rh+ pregnancy. During birth, the mother may be exposed to the infant's blood, and this causes the development of antibodies, which may affect the health of subsequent Rh+ pregnancies.  Rho(D) Immune Globulin is a medicine given by intramuscular injection that is used to prevent this immunological condition.   The medicine is a solution of IgG anti-D (anti-RhD) antibodies that bind to, and lead to the destruction of, fetal Rh D positive red blood cells that have passed from the fetal circulation to the maternal circulation.

Well, most of the medical terminology, disease, their identification, and treatment are not easily understood by commoners like us.  The simplest of the things are : Never indulge in Self medication, Go to the Doctor as immediately as you have early symptoms, Have complete faith in the Doctor, take the medicines as prescribed, follow the instructions given, go compulsorily for after check ups – most likely the disease or disorder could be controlled or eliminated.

Here is something interesting read from  Insurance Journal  : - [http://www.insurancejournal.com/news/east/2012/03/19/239960.htm]

A Richmond, Virginia, woman has been convicted on 35 counts of health care fraud and other charges.  Federal prosecutors say a U.S. District Court jury found 49-yar-old Veronica Sharon Cunningham guilty last Thursday after a three-day trial.

According to court papers, Cunningham owned and operated Community Neurological Services, which administered intravenous immune globulin to patients suffering from immune deficiency disorders. Cunningham was accused of regularly billing insurance companies and the Medicare and Medicaid programs for intravenous immune globulin not actually administered.

The jury convicted her on 26 counts of health care fraud, eight counts of falsifying patient health care records and one count of filing a false tax return. Cunningham faces a maximum of 303 years in prison when she is sentenced on May 31

The guilty needs to be punished and laws are severe in US; litigations common. Stringent punishments most likely are to deter others from indulging in similar crimes….

With regards – S. Sampathkumar.

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