Introduction
The United States of America is among countries where healthcare provision has been widely articulated to consumers increasingly demanding transparency and accountability in the costly healthcare system (Sparrow 86-96). Expenditures in healthcare seem to be on an increasing trend an average annual increase of approximately 5%. 2007 healthcare expenses amounted to $2.26 trillion, growing by 10% to 2.25 trillion dollars in 2009.
Based on this trend it is expected that by 2011 the expenses will amount to $2.625 trillion. Records reveal that every year the US economy suffers losses due to frauds linked to healthcare ranging from $20 to over $50 billion. This significantly accounts for approximately 2.0% of total health care budgets. American Justice Department reveals that over $1billion was accrued in settlements and judgments from fraudulent healthcare claims within 2009 (Sparrow 86-96).
Pfizer Company
Pfizer, one of the largest pharmaceutical companies in the United States was involved in historic healthcare fraud in the year 2009. Its subsidiary, Pharmacia & Upjohn Company used inappropriate brands in promoting the sale of several drugs contrary to the Food, Drug, and Cosmetic Act which requires pharmaceutical companies to specify the intended uses of their drug products to consumers.
The drugs wrongly prescribed included; Bextra, Geodon, Zyvox, and Lyrica. These drugs were prescribed for uses that were not medically accepted and not covered by healthcare programs through which Pfizer was to make claims. The overall objective of this action was to defraud the public through false claims submitted to the Government by the company. After being convicted, the company paid total legal fees amounting to over $2.1 billion, criminal charges amounted to approximately $1.2 billion. Their constituent partners Pharmacia & Upjohn were also required to pay over $100 million (Stanton 28-41).
Pfizer was found to be criminally responsible for paying kickbacks to health care providers in support of prescribed drugs manufactured by the company to patients. The company’s intention was purely focused on making a profit without caring about public health concerning health care laws. Consequently, the company agreed to pay $1 billion in legal fees to resolve this allegation in separate ways, involving federal civil settlement and Medicaid civil settlement. The justice department stressed that illegal conduct among healthcare providers will be met with hefty fines to act as a good lesson to others. The priority should focus on patients’ health safety rather than the company’s profits (Allmon 62).
Several reasons are responsible for healthcare fraud in the United States and these include reasons such as the complexity of Medicine which makes patients fully entrust their doctors during treatment. Secondly, ambiguity in payment systems results in organizations deliberately skimming off small extra payments from a large number of claims (Stanton 28-41). Lastly, limited knowledge on fraud compounded with few experts in investigations results in many unresolved cases (Sparrow 86-96). To check this vice several suggestions were put in place. First was the process of building strong human resource capacity through training in checking and evaluation of payment and claims transactions (Grayson 1-3).
Conclusion
Modern fraud detection software should be used in detecting and checking out for health care frauds in the massive database within the healthcare system (Allmon 62). On the other hand, companies should also install their internal compliance programs which coordinate in line with local laws and regulations within the healthcare system. Lastly, adequate consumer education to citizens should be done with the sole objective of making healthcare seekers know their rights.
Works Cited
Allmon, Andrea. “Deception Detection, Intelligent Software Keeps Medicare Fraud in Check.” Healthcare Informatics, 22 (2005): 62.
Grayson, Matt. “License to Steal: Combating Health Care Fraud.” Journal of State Government, 71 (1998): 1-3.
Sparrow, Malcolm. Health Care Fraud Control; Understanding the Challenge. Journal of Insurance Medicine, 28 (1996): 86-96.
Stanton, Thomas. “Fraud-and-Abuse Enforcement in Medicare: Finding Middle Ground.” Health Affairs, 20 (2001):28-41.