HEALHCARE FRAUD AND ABUSE IN INDIA

Abuse involves misuse of the available healthcare systems with the goal to gain illegally. Healthcare fraud and abuse are characterized by fraudulent activities in health insurance, drug administration, and medical services. 1 Healthcare fraud occurs when individuals or organizations defraud a health program initiated by the government or an insurance company. The activities involved in healthcare fraud continues to evolve and change as people continue to find new ways to evade the law. Fraudulent activities in healthcare results in different damages that harm both the general public and the government. This is because in a bid to impress government inspectors visiting hospitals, medical colleges hired fake and dummy outpatients from nearby slums to act as real patients. Most of these people are admitted without being diagnosed with any medical problem.

India’s medical education system is ineffective and requires immediate review. It is characterized by extensive deceit and unethical education practices that are increasing the intensity of community healthcare problem that the country is facing since it is one of the fastest growing nations, but still an impoverished nation. This problem of inexperienced and unqualified doctors is spread out beyond India’s borders. Another form of healthcare fraud and abuse that has been rampant in India and even outside the country is the unlawful distribution and prescription of opioid an action that constitutes health care fraud. 4Indian doctors in India and even the United States have been arrested and convicted on counts of distribution of controlled elements such as oxycodone and hydrocodone.

Most of these doctors prescribe fentanyl and oxycodone to their patients without any legal medical purpose. This includes making illegal bills for medical tests that are never performed. Most perform EKGs on their patients so that later on they can order nuclear stress tests that they did not administer. Once people bribe to be awarded contracts, they end up supplying or constructing defective products and facilities which interfere with the quality of healthcare. As a result, the general public does not receive the desired healthcare, while the government is defrauded of its revenue through the supply of substandard products. Most of the perpetrators of this medical crimes are government procurement officials who abuse their authority to enrich themselves through government contracts.

They collaborate with medical practitioners and unscrupulous business persons in the pharmaceutical industry. The medical council is another significant contributor towards the healthcare fraud and abuse in India. Corporate hospitals engage in unprincipled practices by undertaking redundant diagnostic examinations and surgical processes to acquire money from the needy patients. They do this to achieve their revenue targets while flouting government regulations and guidelines on how to treat patients from disadvantaged backgrounds. The government also has a role to play in the fraud and inefficiency of the MCI. This is evident based on how the government succumbed to amendments and regulations orchestrated by the MCI which deleted the statements “and association of professional doctors” this is return exempted the professional association of doctors from the MCI code of morals and ethics in 2002.

The said amendment encouraged corruption among the organizations of medical professionals. External fraud refers to claims by either entities or individuals such as policyholders, beneficiaries, vendors, healthcare service providers, and vendors against a firm. On the other hand, internal fraud is carried out against a policyholder or its firm by other workers like executive managers or agents. Eligibility fraud is also common in India this constitutes the falsification of details provided about the insured’s pre-existing diseases, employment status and information about the dependents. Under this situation, the beneficiary is paid illegal benefits for instance when the person submits a claim for the dependents or relatives who are not covered by the policy in question. Another example is when a part-time employee is not covered under some healthcare plan as considered by the firm for full-time employees, by generating false details with any human resource the employee will be able to receive benefits.

Medical identity theft is also widespread in India and most parts of the world. Thousands of people fall victim to this crime on an annual basis. Therefore, it is essential that people should be aware of identity thefts in the medical industry. In medical identity theft, an individual’s name or other personal details are used without the authorization or knowledge of the particular individual to acquire medical goods and services. 12 Additionally, the stolen identity can be utilized to submit false insurance claims. This will seal any loopholes for fraud from both parties. The Indian insurance act should be reviewed to give a better definition of insurance fraud and consequences of such crime under the penal code. Most culprits have been able to evade the law thus the government should impose stricter laws which will be enforced effectively.

Additionally, the medical council of India should be abolished and replaced with a more formidable organization that can effectively regulate and inspect medical colleges to ensure that they offer quality education that is relevant in the healthcare industry. The council should be well constituted to ensure that doctors exercise the highest level of professionalism and ethics this will prevent them from abusing their authority and knowledge by charging patients unnecessary costs for diagnosis and operations. "Medical Council of India Largely Responsible for Corruption in Health Care, Reveals Committee. " Firstpost. Last modified April 29, 2016. https://www. firstpost. Das, Jishnu, Alaka Holla, Aakash Mohpal, and Karthik Muralidharan.  Quality and Accountability in Healthcare Delivery Audit-Study Evidence from Primary Care in India. Fels, Mira.  Making Sense of Corruption in India: An Investigation into the Logic of Bribery.