...Health Insurance Fraud By: WAHEED ALKHAMEES KHALED ALNAFEE Further Issues Hospital Administration PA 551 Master of Health and Hospital Administration (Parallel) King Saud University One:- Introduction Definition Insurance is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. An insurer, or insurance carrier, is a company selling the insurance; the insured, or policyholder, is the person or entity buying the insurance policy. The amount of money to be charged for a certain amount of insurance coverage is called the premium. Risk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice. The transaction involves the insured assuming a guaranteed and known relatively small loss in the form of payment to the insurer in exchange for the insurer's promise to compensate (indemnify) the insured in the case of a financial (personal) loss. The insured receives a contract, called the insurance policy, which details the conditions and circumstances under which the insured will be financially compensated. Types of Insurance Services Insurance can take a number of different forms. Some of these types: Auto insurance Auto insurance protects the policyholder against financial loss in the event of an incident involving a vehicle they own, such as...
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...investments and improve their health. The scams profiled include home-improvement projects, where a person takes the victim's money but does not perform the work promised; investment frauds and controlling their money for the future; and health and medical scams, which promise the equipment and service that do not perform as advertised. Also, research was taken from a survey from a rehab center with most of them senior citizens. The primary advice for preventing such white-collar crimes is to never give money for a product, service, or investment based upon a person's or business promise without first conducting a thorough background check. Key Terms: Senior Citizen, White Collar Crime, Prevention, Con Artists White Collar Crime against Senior Citizens Senior citizens are some of the most vulnerable targets when it comes to fraud and scam within white collar crime. There are many reasons why many people target the senior citizens and elderly mostly including but not limited to: because they are too polite and have good manners. For example, the elderly will usually not say no to people they are talking to. One of the main reasons that senior citizens have a problem is when they do find out about the scam and/or fraud; they are too embarrassed to report to the police or even their family members. This paper will focus on why the elderly are being targeted, the different types of white collar crime committed against them, and how they can be prevented. After speaking with a majority...
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...(Anderson). The Federal Trade Commission estimates that more than 9 million individuals are victims of identity theft each year. The Justice Department puts the figure at more than 3.5 million households (Anderson). Anyone can become a victim of identity theft and it is not limited to the financial activities of one’s life. People’s identity is also stolen in order to commit criminal activities. Both activities are defined as fraud and are punishable by law if caught. Financial identity theft or fraud includes bank fraud, credit card fraud, computer and telecommunications fraud, social program fraud, tax refund fraud, and mail fraud. In fact, a total of 25 types of financial identity fraud are listed and investigated by the United States Secret Service (Obringer). In 1997, Secret Service agents made approximately 10,000 financial crime arrests which 94 percent involved identity theft (Obringer). Fifteen years later, Javelin Strategy & Research reports that over 12 million financial identity theft cases were reported (Javelin Strategy & Research). Other types of identity theft usually involve financial elements as well but are typically committed to fund some sort of criminal enterprise. Criminal activities include gaining someone else’s identity in order to enter a country, get special permits, hide one's own identity, or commit acts of terrorism. Criminal identity theft is relatively easy to commit by simply providing someone else’s name and birth date...
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...Health care Fraud Health care fraud is a crime that has a significant effect on the private and public health care payment system. According to the Federal Bureau of Investigation, all health care programs are subject to fraud with Medicare and Medicaid being the most visible. It is estimated that fraudulent billings to both private and public health care programs are between 3 and 10 percent of total health care programs expenditures. The most recent Centers for Medicare and Medicaid (CMS) statistical estimates project that total health care expenditures are estimated to total $2.4 trillion, representing 14 percent of the gross domestic product. By the year 2016, CMS also estimates that by the year 2016, the total health care spending is to exceed $4.14 trillion, representing 19.6 percent of the GDP. As one can see, the tens of billions of dollars lost due to health care fraud is a serious financial issue that affects the healthcare system as a whole and affects patients, taxpayers, and government through higher health care costs, insurance premiums and taxes. Health care fraud is defined in Title 18, United States Code (U.S.C) s. 1347 as “whoever knowing and willfully executes or attempts to execute a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations or promises, any money or property owned by or under the custody or control of, any health care benefit program.” In other words, it is intentional...
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...Minkow’s stock in the company had a market value exceeding $100 million, and the total market value of ZZZZ Best surpassed $200 million." (Knapp) Less than two years later, Minkow had been exposed as a fast talking con artist who bilked his closest friends and Wall Street out of millions of dollars. Barry Minkow began serving a twenty-five-year prison sentence after being tried and convicted on fifty-seven counts of securities fraud. ZZZZ Best differed in part from a typical Ponzi scheme in that Minkow’s carpet-cleaning business was very real. "Indeed, the carpet-cleaning division won high marks for its quality." (Miller) However, its insurance restoration division, which eventually accounted for 86 percent of company revenues, was nonexistent. Minkow raised money by factoring his account receivables for work under contract, as well as floating funds through several banks in an elaborate check kiting scheme. The story of Barry Minkow is hardly an isolated case. According to the Association of Certified Fraud Examiners, "the estimated annual cost of occupational fraud to American employers is...
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...Nathan Mueller ING Fraud Alec Doig Fraud Examination 3-26-2014 After going to the Duluth Prison Camp, one most interesting and informative field trips of my academic career, I was intrigued by two of the white-collar criminals who spoke to us. Nate Mueller and Brad Weaver not only caught my attention during our visit to the DPC, but also made me want to learn more about them, their crime, and why they got caught. After initial research and with the information I had gained from the prison, I decided to focus on Nate Mueller for my paper. The main reason for choosing Nate over Brad was that I have so much in common with him. Most importantly, Nate was an accountant. Not only was he an accountant, but also an accountant working a mid-level job in corporate America, a job that I could easily see myself doing. He grew up in central Minnesota in an upper middle class family and attended Gustavus Adolphus College (Duluth News Tribune, 2012). He was a very intelligent and knowledgeable accountant in addition to being very personable. All of these similarities really intrigued me and also scared me about who can commit a fraud and how easily the lines can be crossed. Now onto Nathan Mueller—the criminal. Nate was working as an accounting manager for ING Resurgence Corporation in their re-insurance division (St. Anthony, 2008). Before ING Resurgence, a subsidiary of the ING GROUP, had acquired ReliaStar Life Insurance Company, Nate began learning the new accounting information...
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...Identity Theft Abstract This research paper will examine what is known about identity theft. The paper begins with defining the crime and its background, followed by a review of the patterns and incidences of identity theft. This review will include data on the extent and costs of this crime. Discussion will then focus on victims and perpetrators of identity theft. Common techniques used by identity thieves will be explored along with tips to protect consumers and businesses from having their identities stolen or data breached. Legislation in place to prevent and prosecute identity theft will be discussed. How to report identity theft is also explained. Defining Identity Theft The U.S. Department of Justice defines identity theft, also called identity fraud, as “all types of crime in which someone wrongfully obtains and uses another person’s personal data in some way that involves fraud or deception, typically for economic gain” (U.S. Department of Justice, 2015). Identity thieves use personal data such as Social Security numbers, bank account or credit card numbers to personally profit at the victim’s expense. These breaches allow thieves to take funds out of bank accounts or in the worst cases, take over a victim’s identity completely, running up huge debts and committing crimes using the victim’s name. Victims not only suffer the out-of-pocket financial losses, but they may have to rebuild their reputation in the community due...
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...How HIPPAA Violations Affect the Medical Billing Process, Part Two Amber Padgett HCR/220 October 19, 2014 Felecia Pettit-Wallace The purpose of this paper is to relate to ways that the Health Insurance Portability and Accountability Act (HIPAA) violations may affect the medical billing process. While researching, the findings conclude that confidentiality of health information was adopted centuries ago. The findings of the research show that although, HIPAA laws have been put into place to protect the privacy and confidential heath information of patients; HIPAA laws are sometimes violated. The medical billing coders are sometimes careless when handling confidential information; however medical health records should be protected adequately. The coder that violates the HIPAA laws concerning the confidentiality and privacy of patient health information can suffer serious ramifications. The ramifications of these violations could result in serious penalties such as disciplinary actions by the employer, monetary fines, and jail time, or both. HIPAA violations ranks number one among the complaints received by the Office of Civil Rights each year. Humans take pleasure in the right to privacy in every aspect of life. The right of protecting the confidentiality and privacy of identifiable personal health information takes first priority and is greatly cherished among most. The Hippocratic Oath, dating back centuries required physicians to keep medical information concerning...
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...My Philosophical View on Gattaca My Philosophical View on Gattaca I personally always thought that knowing what would happen to me and my life would be a great way to avoid the problems that I might encounter, but after watching Gattaca (1997), I am absolutely glad that I get to face even the smallest challenges in my life. Gattaca (1997) is a good movie overall, but to think of the problems I face on a daily basis makes me glad I am a “God child”, (Gattaca, 1997). In the movie any child born that has not been confirmed by a geneticist of being perfect, or as close as possible to perfect, is known as a “God child, degenerate, faith birth, or in-valid”, (Gattaca, 1997) and any child that is confirmed by a geneticist, to be perfect, is known as a “valid”, (Gattaca, 1997) child or person. Gattaca (1997) is actually a company that runs a space program and only hires “valid” individuals to work for them, because they will be going into space and the directors of Gattaca (1997) do not want anyone that would have a genetic defect and that may possibly pass away while travelling to their destination or while they are in space. The movie Gattaca (1997) is a good film to watch to learn what geneticists need to stay away from. The following is my view on the philosophical problems with the movie Gattaca (1997) and to show that genetics should be left to God, or whoever, and not to humans. The whole premise of the movie, Gattaca (1997), is how...
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...Healthcare Fraud and Abuse Under HIPPA, “fraud is defined as knowingly, and willfully executes or attempts to execute a scheme… to defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by…any healthcare benefit.” Unlike Fraud, abuse is, “means that are improper, inappropriate, outside of acceptable standards of professional conduct or medically unnecessary.” Health care fraud arises from an individual or group of individuals filing of a dishonest health care claim in order to turn it into a profit. Abuse; however, is harder for the investigator to identify and establish if the act was committed knowingly, willfully, and intentionally. Healthcare industry is one of the fastest growing sectors of the US economy; almost 10% of the US’s national GDP is consumed by the health care industry. According to Forbes’s report, the US National Healthcare expenditure of 2012 was nearly $3 Trillion. According to the National Healthcare Anti-Fraud Association, nearly $60 Billion is lost to healthcare fraud each year. The healthcare industry is an enormous market; therefore, making it easier for healthcare providers to take advantage of the American population. This paper will focus on why fraud and abuse occurs, different types of fraud, example cases of fraud and abuse, impact to present day healthcare industry, and potential solutions to fixing and preventing fraud and abuse from occurring...
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...Data Mining for Fraud Detection: Toward an Improvement on Internal Control Systems? Mieke Jans, Nadine Lybaert, Koen Vanhoof Abstract Fraud is a million dollar business and it’s increasing every year. The numbers are shocking, all the more because over one third of all frauds are detected by ’chance’ means. The second best detection method is internal control. As a result, it would be advisable to search for improvement of internal control systems. Taking into consideration the promising success stories of companies selling data mining software, along with the positive results of research in this area, we evaluate the use of data mining techniques for the purpose of fraud detection. Are we talking about real success stories, or salesmanship? For answering this, first a theoretical background is given about fraud, internal control, data mining and supervised versus unsupervised learning. Starting from this background, it is interesting to investigate the use of data mining techniques for detection of asset misappropriation, starting from unsupervised data. In this study, procurement fraud stands as an example of asset misappropriation. Data are provided by an international service-sector company. After mapping out the purchasing process, ’hot spots’ are identified, resulting in a series of known frauds and unknown frauds as object of the study. 1 Introduction Fraud is a million dollar business and it is increasing every year. ”45% of companies worldwide have fallen victim...
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...payers and Care Delivery Organizations (CDO.) (Gonzalez, 2014) This writing assignment will take a look at the adoption of Electronic Medical records and show the strengths and weaknesses of overhauling medical records from paper to digital. Context The purpose of writing this paper is to give me a better understanding on how information systems can help the medical field. However, it is important to understand that you cannot just overhaul the current system in place. There needs to be a process involved to get everyone at stake the proper training and information needed to undergo such a large transition. Introduction Electronic Medical Records are basically electronic versions of paper-based medical records. An Electronic Medical Record (EMR) is essentially an electronic record of health related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff in one healthcare organization. Electronic medical record systems lie at the center of any computerized health information system. (Takvorian, 2007) There are many functions associated with patient health records. Not only is the record used to document patient care, but the record is also used for financial and legal information, and research and quality improvement purposes. Because all this information must be shared among many professionals who...
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...(Online) Table of Contents ABSTRACT 3 INTRODUCTION 4 Introduction to the Problem 4 Background of the Study 4 Statement of the Problem 4 Purpose of the Research 5 Research Questions 5 Significance of the Research 5 LITERATURE REVIEW 7 CONCLUSION AND RECOMMENDATIONS 19 ABSTRACT This paper investigates White Collar Crime (“WCC) in society and the affects it has on businesses in today’s society, the cost and statistics involved with white collar crime and the difference in how white collar crime and street crimes are dealt with. While white collar crime has existed for many decades, I have conducted research regarding the definition of white collar crime, the history of white collar crime, the different types of white collar crime that affect businesses directly and indirectly, goals of white collar crime, fraud statistics and the cost factors related to white collar crime. White collar crimes and business ethics play hand in hand with one another and often cross the line with one another into criminal behavior. White collar crimes have played a very instrumental part in our downward economy over the past five years, and the level of trust given by society to corporations and employers entrusted with their life earnings has changed dramatically. My research will include factors that contribute to this problem and how white collar crime affects the management and operations of business organizations; what part modern technology plays...
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...utilization of the scarce resources at its disposal. This study is an attempt to deduce a country-specific conceptual framework for forensic accounting, which can be replicated, with suitable adaptations, to other countries with similar cultural backgrounds, and put forth some theory-supported suggestions to help guide future research in the area. Keywords: forensic accounting, conceptual framework, institutional theory, foucault Introduction: The rise in the white collar crimes, where evidences are comparatively moreobscure and difficult to detect (Gottschalk, 2011), has necessitated equipping of auditors with forensic skills, particularly over the recent years (DiGabriele, 2009a; Carnes & Gierlasinski, 2001). In the aftermath of several accounting scandals such as Enron and WorldCom in the USA, HIH Insurance in Australia, Royal Ahold in the Netherlands, Parmalat in Italy, and Equitable Life Assurance Society in the UK (Kleinman & Anandarajan, 2011), as well as the collapse of one of the “Big Five” auditing firms (Arthur Anderson), and the two episodes of financial crises that followed afterwards, awareness about white-collar frauds committed...
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...This research paper attempts to elucidate how each character in the play A Raisin in the Sun written in 1959 by Lorraine Hansberry wants to achieve a dream which represents certain characteristics in common with the American Dream. Furthermore, this paper seeks to reveal to what extent aspects of the American Dreams, such as the ideal of justice or equality between the races, have been fulfilled by analyzing how these aspects are presented in the play. The Younger family is living in Chicago and is facing financial problems as well as social problems such as discrimination. As Mama’s husband died the family receives 10.000$ insurance money, which gives each family member the opportunity to fulfill their dream. Mama herself wants to buy a new house for the family, her daughter pursues the dream of becoming a doctor and her son Walter wants to open a liquor store. However, the fact that Walter’s wife Ruth is pregnant complicates the situation. Mama eventually decides to buy a new house in a white neighborhood and entrusts Walter with the rest of the money, but he loses all the money through a fraud, although he should have left some money to fund Beneatha’s education. Eventually, at the end of the drama, Mr. Lindner offers money to buy the Youngers out of their new house, but Walter stands up against him and declines the offer....
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