Healthcare fraud and abuse Essays

Healthcare fraud and abuse Essays Healthcare fraud and abuse Paper Healthcare fraud and abuse Paper As a Denzel Washington fan, I remembered a movie a couple of years back with a relation to health care entitled John Q.   It depicts a man undergoing hardships to get his son a heart transplant because his HMO would not cover it due to his employee status. Although the plot did not center on health care per se, it got me thinking about how far my own HMO coverage would go. This paper aims to tackle 3 types of abuse and fraud in healthcare in order to prevent and direct much needed resources to those deserving. Along with the advances that we have achieved come those with ill-intent out to further themselves hence health care fraud and abuse.   This is defined in Qui Tam FYI as, â€Å"deceptive means used by an organization to profit from government healthcare agreements. That definition has more recently been extended to include not only deception, but also unreasonable ignorance of the rules.† In 1985, to combat the growing threats against this criminal activity, the NHCAA or National Health Care Antifraud Association was established and has turned to become the leading American organization directed towards health insurance fraud. Their mission statement: â€Å"To protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud.†3   Ã‚  We go on to discuss the different type of fraud and abuse. The most rampant is the misrepresentation of goods and services.   A concrete example is when someone is treated for a common cold but when forwarded to the HMO it would appear that the patient was tested for pneumonia and a full blood test was conducted when no such activity was done. The hospital or clinic would then receive compensation for something which was fictitious.   A simple way to prevent this would be to confirm with the person examined unless they were in on it too. Another is padding the costs of medical services and medicines.   Purchase prices for medicine are sometimes marked up 200% onwards under the guise of increased cost. With services however, the modus operandi is billing for each separate exam rather than the comprehensive package therefore increasing the total price.   Both instances would increase revenues while maintaining overhead costs. Lastly, some institutions recommend treatment or exams which are unnecessary.   They plague on people’s fears and tell them it is better safe than to be sorry.   The difference between this example and the first one is that the tests actually took place.   It was just not needed.   In the person suffering from the cold example, a doctor could say that he needs to go through a battery of tests in order to eliminate other possibilities when the symptoms shown were very negligible or unfounded. Healthcare fraud and abuse is covered in the United States by the Federal False Claims Act.   This law protects victims and with penalties like fines and in sever cases even prison sentences.   It provides that any citizen can on the behalf of the government, file a case against companies or persons engaged in misrepresented activities and also protects that citizen from legal repercussions. Medical insurance companies also hire independent auditors and investigators to validate the claims made by clients and establishments to defend against potential loss from swindlers. â€Å"In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed 26.3 percent of the GDP of the United States, the largest of any country in the whole wide world.† That amount of money will attract people with ill-intent who always try to make a quick buck.   This will be a continuing fight from organizations like the NHCAA and governments who want to make sure that persons who deserve medical assistance will always get it. Reference List World Health Organization Report. (2000). Why do health systems matter?   WHO Qui Tam FYI.   â€Å"What is health care fraud?† retrieved 9 March 2008 from quitamfyi.com/healthcare-fraud.html National Health Care Antifraud Association.   Mission Statement retrieved 9 March 2008 from nhcaa.org/eweb/DynamicPage.aspx?webcode=about_nhcaawpscode=WhoWeAre Wikipedia article on health care.   (2008) â€Å"Health Care† retrieved 9 March 2008

An Overview of Game Theory in Sociology

An Overview of Game Theory in Sociology Game theory is a theory of social interaction, which attempts to explain the interaction people have with one another. As the name of the theory suggests, game theory sees human interaction as just that: a game. John Nash, the mathematician who was featured in the movie A Beautiful Mind is one of the inventors of game theory along with mathematician John von Neumann. How Was Game Theory Developed? Game theory was originally an economic and mathematical theory that predicted that human interaction had the characteristics of a game, including strategies, winners and losers, rewards and punishment, and profits and cost. It was initially developed to understand a large variety of economic behaviors, including behavior of firms, markets, and consumers. The use of the game theory has since expanded in the social sciences and has been applied to political, sociological, and psychological behaviors as well. Game theory was first used to describe and model how human populations behave. Some scholars believe that they can actually predict how actual human populations will behave when confronted with situations analogous to the game being studied. This particular view of game theory has been criticized because the assumptions made by the game theorists are often violated. For example, they assume that players always act in a way to directly maximize their wins, when in reality this is not always true. Altruistic and philanthropic behavior would not fit this model. Example of Game Theory We can use the interaction of asking someone out for a date as a simple example of game theory and how there are game-like aspects involved. If you are asking someone out on a date, you will probably have some kind of strategy to â€Å"win† (having the other person agree to go out with you) and â€Å"get rewarded† (have a good time) at a minimal â€Å"cost† to you (you don’t want to spend a large amount of money on the date or do not want to have an unpleasant interaction on the date). Elements of a Game There are three main elements of a game: The playersThe strategies of each playerThe consequences (payoffs) for each player for every possible profile of strategy choices of all players Types of Games There are several different kinds of games that are studies using game theory: Zero-sum game: The players’ interests are in direct conflict with one another. For example, in football, one team wins and the other team loses. If a win equals 1 and a loss equals -1, the sum is zero.Non-zero sum game: The players’ interests are not always in direct conflict, so that there are opportunities for both to gain. For example, when both players choose â€Å"don’t confess† in Prisoner’s Dilemma (see below).Simultaneous move games: Players choose actions simultaneously. For example, in the Prisoner’s Dilemma (see below), each player must anticipate what their opponent is doing at that moment, recognizing that the opponent is doing the same.Sequential move games: Players choose their actions in a particular sequence. For example, in chess or in bargaining/negotiating situations, the player must look ahead in order to know what action to choose now.One-shot games: The play of the game occurs only once. Here, the players are likely to not know much about each other. For example, tipping a waiter on your vacation. Repeated games: The play of the game is repeated with the same players. Prisoner’s Dilemma The prisoner’s dilemma is one of the most popular games studied in game theory that has been portrayed in countless movies and crime television shows. The prisoner’s dilemma shows why two individuals might not agree, even if it appears that it is best to agree. In this scenario, two partners in crime are separated into separate rooms at the police station and given a similar deal. If one testifies against his partner and the partner stays quiet, the betrayer goes free and the partner receives the full sentence (ex: ten years). If both remain silent, both are sentences for a short time in jail (ex: one year) or for a minor charge. If each testifies against the other, each receives a moderate sentence (ex: three years). Each prisoner must choose to either betray or remain silent, and the decision of each is kept from the other. The prisoner’s dilemma can be applied to many other social situations, too, from political science to law to psychology to advertising. Take, for example, the issue of women wearing make-up. Each day across America, several million woman-hours are devoted to an activity with questionable benefit for society. Foregoing makeup would free up fifteen to thirty minutes for each woman every morning. However, if no one wore makeup, there would be great temptation for any one woman to gain an advantage over others by breaking the norm and using mascara, blush, and concealer to hide imperfections and enhance her natural beauty. Once a critical mass wears makeup, the average facade of female beauty is artificially made greater. Not wearing makeup means foregoing the artificial enhancement to beauty. Your beauty relative to what is perceived as average would decrease. Most women therefore wear makeup and what we end up with is a situation that is not ideal for the whole or for the indivi duals, but is based on rational choices by each individual. Assumptions Game Theorists Make The payoffs are known and fixed.All players behave rationally.The rules of the game are common knowledge. Resources and Further Reading Duffy, J. (2010) Lecture Notes: Elements of a Game. pitt.edu/~jduffy/econ1200/Lect01_Slides.pdfAndersen, M.L and Taylor, H.F. (2009). Sociology: The Essentials. Belmont, CA: Thomson Wadsworth.