Fraud involving pharmaceutical companies and healthcare providers constitutes a major source of economic waste affecting countries around the world. In spite of increased awareness of the problem and the application of sophisticated anti-fraud mechanisms, individual actors and agencies continue to defraud public and private health systems.
With rapidly ageing populations and the increased costs of providing long-term care placing substantial pressure upon already overburdened health and social care sectors, healthcare spending will continue to increase worldwide. Unfortunately, this will also bring increased fraud schemes, as fraud perpetrators follow the money – and healthcare presents a target-rich environment. Quantitative data indicates that healthcare fraud has already risen starkly. The World Health Organisation (WHO) estimates that, where losses have been measured and the types of health expenditure have been covered, the average annual cost of fraud totals 7.29 percent of healthcare budgets (Gee and Button, 2014).
CRI Group’s fraud investigators (including forensic accountants and Certified Fraud Examiners) look for red flags and vulnerabilities that may indicate healthcare fraud. CRI Group’s experts have uncovered schemes including billing for services not rendered, up-coding of services, up-coding of items, duplicate claims, unbundling, excessive services, unnecessary services, kickbacks and more. In addition, pharmaceutical companies face the threat of counterfeit medications, which can lead to major financial loss, not to mention dangerous consequences for patients. This is why the strictest measures and prevention strategies are needed for any pharmaceutical or healthcare organisation.
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