ABSTRACT
More than $1 trillion is spent each year on healthcare costs in the United States. Despite the enormous sum of money spent in this area, many Americans continue to be discontented with existing or missing healthcare services. One possible explanation for the disparity between what Americans expect from healthcare and what they get is that a considerable portion of the money the U.S. government pays out is lost to healthcare fraud. In 1992, the Government Accounting Of£ce estimated that losses from fraud and abuse account for about 10 percent of total healthcare spending. That translates to roughly $100 billion each year that winds up in the pockets of fraud perpetrators. Physicians, as traditional patient advocates, are in a unique position to support patients in obtaining and keeping the healthcare services they need by helping to combat fraud. Fraud is generally considered an act of deception or misrepresentation designed to obtain something of value held by another. Fraud may be measured in a particular case by determining whether the scheme demonstrated a departure from fundamental honesty, moral uprightness, fair play, or candid dealings in the general life of the community. Healthcare fraud mainly deals with false claims, kickbacks, and other schemes to divert money from the government. Fraud is intentional. When physicians submit Medicare claims for services never performed, they are committing fraud. When podiatrists misrepresent compensable services they performed that are truly not compensable, they are also committing fraud. When providers deliver services but bill for others that pay better than those performed, or bill for unnecessary services, they are also practicing fraud. Abuse, which is often dif£cult to distinguish from fraud, may occur when health professionals use methods or practices for which there may be a medical purpose but the use of which appears extravagant, improper, unnecessarily costly, or at odds with customary medical practice.
