Private Health Insurance and Fraud Issues

Table of Contents

Organizations and professionals in the healthcare industry are held responsible by the law to ensure that they perform their activities within legal frameworks. Employees are answerable to their employers to adhere to their agreements contained in employment contracts. Accountability in healthcare organizations should be characterized by a top-down pattern whereby the leaders demonstrate to their followers how to be responsible for their actions.

The entire leadership in a facility should have a strong feeling of accountability for professional roles and the whole firm (Fossen & König, 2017). Answerability requires practitioners to possess the ability to carry out interventions, accept ownership for actions, and have the power to perform their duties (Sommers, Blendon, Orav, & Epstein, 2016). This essay describes how an individual can avoid fraud and inefficiencies in third-party payments and the challenges consumers face when enrolled in private insurance. Also, it defines the stream of finances in care organizations and explains the strategies to empower users.

Prevention of Abuses and Inefficiencies

Fraud and inefficiencies concerning intermediary compensation have been shown to cost the sector billions of dollars every year. Providers’ reputation and revenues could be adversely affected by these issues if they do not adopt prevention policies and compliance programs. Organizations can prevent abuses and inefficiencies by adhering to the “Federal False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law” (Mulligan, 2016, p. 43).

The Federal False Claims Act prohibits persons from deliberately submitting fraudulent claims to public and private agencies. Anti-Kickback Statute discourages individuals and firms from receiving remuneration to induce referrals of services. The Physician Self-Referral Law prevents entities from making recommendations for particular services payable by government programs to entities in which an immediate family member has investment interests (Mulligan, 2016). Also, facilities can avoid revenue and reputation costs associated with abuses and inefficiencies by utilizing an evidence-based program.

Such a plan should be founded on a culture that improves prevention and resolution of actions or events contrary to the government laws. For example, the management should strive toward developing and distributing programs to educate and train staff. Overbilling is a common abuse that is experienced when payments are made to third parties. This matter can be prevented if providers offer honest information and remain ethical in their operations (Mulligan, 2016). Finally, inefficiency due to manipulation of reimbursements can be avoided by launching federal investigations to that unearth and help to charge culprits.

Definition of Funds in the Care Organization

The stream of finances in the care organization refers to the framework for tracking how money is distributed from health resources to persons receiving services via third-party agents such as Medicare (Mulligan, 2016). Moreover, it can be defined as the route through which cash allocated by the federal government for health services is availed to people who need medical attention.


Private insurance consumers face a myriad of challenges that can negatively impact their health and wellbeing. For example, a customer who enrolls in a personal insurance plan may pay relatively high premiums since their costs are expensive in comparison to public health insurance (Fossen & König, 2017).

Consumers of these covers could also realize that some medical services would not be compensated. This means that a consumer of private insurance only chooses services that would be covered. In addition, these customers face high levels of inequality. In this context, individuals who pay high premiums gain access to priority treatment (Sommers et al., 2016). Another problem is that private insurance covers apply to particular facilities, unlike public health insurance plans that are accepted across all hospitals.

Methods of Empowering Customers

If consumers of healthcare products are empowered, outcomes are consequently improved by providers. Organizations and professionals could utilize different strategies to empower their clients, such as assisting them to comprehend several aspects of the sector, providing satisfactory services at affordable rates, and helping patients to abide by what they are taught (Carman, Eibner, & Paddock, 2015).

In addition, facilities and professionals can strive toward encouraging users to frame and conceive questions that are designed to yield solutions to health issues. Finally, it would be necessary for management teams of care organizations to establish excellent relationships with their clients so that the latter would feel appreciated (Sommers et al., 2016). Notably, all these approaches are founded on the view that patients constitute an essential category of stakeholders in the industry whose needs should always be met.


Individuals and firms in the healthcare sector are liable for their actions and, consequently, they should act in ethical and honest ways. Some of the laws that can be applied to prevent abuses and inefficiencies are the Federal False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law. Provision of truthful information and investigating payment frauds can also be used to avoid such matters in the future. The flow of funds traces how money is availed from the government via intermediaries to persons seeking care. Some of the challenges that users face in the private insurance are inequality, high premiums, and limited services. Customers can be empowered through education, excellent care, and unique relationships.


Carman, K. G., Eibner, C., & Paddock, S. M. (2015). Trends in health insurance enrollment, 2013–15. Health Affairs, 34(6), 1044-1048.

Fossen, F. M., & König, J. (2017). Public health insurance, individual health, and entry into self-employment. Small Business Economics, 49(3), 647-669.

Mulligan, J. (2016). Insurance accounts: The cultural logics of health care financing. Medical Anthropology Quarterly, 30(1), 37-61.

Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Internal Medicine, 176(10), 1501-1509.

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