Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

Front matter

Terry L. Leap

Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

Health Care Fraud and What to Do about It

Contents

Preface Acknowledgments

Introduction: The Big Picture

3. Fraud in Fee-for-Service and Managed Care: Different Sides of the Same Coin

Preface

The health care systems in developed countries today employ diagnostic methods and treatment regimes that are light years ahead of the health care available when even the youngest readers of this book were born. Medical conditions once considered incurable or life threatening are now treated routinely, causing only minor disruptions to the patient’s life. Bioengineering and health care in the early part of the twenty- first century seemingly border on the miraculous.

But a dark side also exists. Fraud and abuse are pervasive elements of the vast health care systems of advanced industrial nations such as the United States and the European Union. A small but troublesome minority of health care providers submit bills for services they have never performed. Others provide treatments that their patients do not need, and they steal hundreds of millions of dollars from the Medicare and Medicaid programs through false billings. Still others take kickbacks from pharmaceutical manufacturers, hospitals, and ambulance companies. To make a quick buck, a few of the most nefarious health care “professionals” are willing to place the welfare or even the lives of their patients in jeopardy.

Health care is what criminologists call a “criminogenic industry.” This book illustrates how the U.S. health care system provides a fertile environment for fraud and abuse on a scale that makes it among the most serious of all white-collar crimes.

Acknowledgments

I owe a deep debt of gratitude to Suzanne Gordon, coeditor of the Culture and Politics of Health Care Work series of Cornell’s ILR Press. Her insights and meticulous reading and rereading of the manuscript forced me to think critically about the complex social problem of health care fraud and abuse. Also, Fran Benson, editorial director of ILR Press, provided her usual strong support and encouragement. This book is the fourth project that Fran and I have worked on together during the past three decades. I also thank Myron Fottler, who served as a reviewer for the book, as well as a second anonymous reviewer. In addition, I would like to express my appreciation to staff at Cornell University Press, including Kitty Liu, Ange Romeo-Hall and Katy Meigs for their extensive editorial work, and to the production and marketing departments. Finally, I want to thank Bo, my cat and wonderful friend for nearly eighteen years. He sat at my feet throughout the preparation of most of this manuscript—as well as two previous books that I published with Cornell University Press. Unfortunately, he died before this book was published.

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PHANTOM BILLING, FAKE PRESCRIPTIONS, AND THE HIGH COST OF MEDICINE