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Ghost Network
Ghost network refers to a form of healthcare insurance fraud where providers are listed as in a health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ... plan, but are unable to provide care. These ghost providers may no longer be eligible to practice, may have retired, may no longer accept new patients, may not actually part of the network, or may not exist. The inclusion of ghost providers may be intentional to exaggerate plan availability to encourage enrollment and falsely meet healthcare network adequacy. Ghost networks can negatively affect the quality of service received by plan participants and the delayed care may negatively impact patients. United States Health insurance carriers may decline to make up-to-date directories of participating providers available o ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Care Fraud
Health care fraud includes "snake oil" marketing, health insurance fraud, drug fraud, and medical fraud. Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law. Damages from fraud can be recovered by use of the False Claims Act, most commonly under the ''qui tam'' provisions which rewards an individual for being a "whistleblower", or relator (law). Recent news and statistics The FBI estimates that ''Health Care Fraud'' costs American tax payers $80 billion a year. Of this amount $2.5 billion was recovered through ''False Claims Act'' cases in FY 2010. Most of these cases were filed under ''qui tam'' provisions. Over the course of FY 2010, ''whistleblowers'' were paid a total of $307,620,401.00 for their part in bringing the cases forward. ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Insurance Fraud
Insurance fraud is any intentional act committed to deceive or mislead an insurance company during the application or claims process, or the wrongful denial of a legitimate claim by an insurance company. It occurs when a claimant knowingly attempts to obtain a benefit or advantage they are not entitled to receive, or when an insurer knowingly denies a benefit or advantage that is due to the insured. According to the United States Federal Bureau of Investigation, the most common schemes include premium diversion, fee churning, asset diversion, and workers compensation fraud. False insurance claims are insurance claims filed with the fraudulent intention towards an insurance provider. Fraudulent claims account for a significant portion of all claims received by insurers, and cost billions of dollars annually. Insurance fraud poses a significant problem, and governments and other organizations try to deter such activity. Studies suggest that the greatest total dollar amount of frau ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Care Provider
A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often receive payments for their services rendered from health insurance providers. In the United States, the Department of Health and Human Services defines a health care provider as any "person or organization who furnishes, bills, or is paid for health care in the normal course of business." Individual providers In the United States, the law defines a healthcare provider as a "doctor of medicine or osteopathy who is authorized to practice medicine or surgery" by the state, or anyone else designated by the United States Secretary of Labor as being able to provide health care services. In general, this is seen to include: * Physician, a professional who practices medicine * Advanced practice provider, a trained health worker who has a defin ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Insurance
Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment". A health insurance policy i ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Network Adequacy
Network adequacy in healthcare in the United States is having sufficient providers within a health plan network to ensure reasonable and timely access to care. Health insurance plans may include ghost providers to falsely maintain compliance. There are no federal standards, though several states, including California California () is a U.S. state, state in the Western United States that lies on the West Coast of the United States, Pacific Coast. It borders Oregon to the north, Nevada and Arizona to the east, and shares Mexico–United States border, an ..., have passed legislation to ensure minimum network adequacy. References Healthcare in the United States {{law-stub ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Petrie-Flom Center
Harvard Law School (HLS) is the law school of Harvard University, a private Private or privates may refer to: Music * "In Private", by Dusty Springfield from the 1990 album ''Reputation'' * Private (band), a Denmark-based band * "Private" (Ryōko Hirosue song), from the 1999 album ''Private'', written and also recorded ... research university in Cambridge, Massachusetts. Founded in 1817, Harvard Law School is the oldest law school in continuous operation in the United States. Each class in the three-year Juris Doctor, JD program has approximately 560 students, which is among the largest of the top 150 ranked law schools in the United States. The first-year class is broken into seven sections of approximately 80 students, who take most first-year classes together. Aside from the JD program, Harvard also awards both Master of Laws, LLM and Doctor of Juridical Science, SJD degrees. HLS is home to the world's largest academic law library. The school has an estimated 115 full-t ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
