Greg Pimstone On Escalating Healthcare Fraud and The Severe Exploitation of The Affordable Care Act


Healthcare fraud is growing at such an alarming rate in America that it is becoming the most profitable illegitimate business in the nation today. This crime is now a serious threat to public safety in the nation. However, it has been in existence in the country even before the Covid-19 pandemic and the introduction of the Affordable Care Act (ACA). As inall industries, fraud escalates exponentially with the rapid advances in technology, and the healthcare sector is no exception. The authorities in the United States need to impose more stringent internal controls and risk management assessment measures to curtail this menace. Above all, the authorities should intensify their efforts to apprehend and punish the culprits of this crime.

Gregory Pimstone advocates the eradication of healthcare fraud

Greg Pimstone is a renowned legal expert in America and is currently a partner of a prominent national healthcare litigation practice firm, Manatt. He explains that complicit doctors and other immoral medical professionals are the primary culprits of healthcare fraud. These offenders have direct access to the healthcare system and can easily circumvent the internal controls without arousing suspicion. They can easily execute transactions that look legitimate at first glance but are actually illegal on close analysis. This development weakens the country’s healthcare system and endangers the public.

The extent of healthcare fraud in the country

The National Money Laundering Assessment Report of 2018 exposes the extent of healthcare fraud in America. The crime is one of the largest sources for generating illegitimate funds accounting for more than $100B in proceeds. This is equivalent to 35% of all the illegal money criminals in America launder. This is an extremely distributing scenario, and healthcare consumers are the worst suffers.

Healthcare fraud in America begins with the blatant abuse of PPO health schemes by healthcare providers. They buy private health insurance policies for poor patients without any insurance cover and even pay their premiums using various scams.They then waive their own cost-sharing obligations under these policies. However, they ensure all of their patients get free treatment from the out-the-network provider.

Consumers having to incur exorbitant healthcare costs

Once the patients’ treatment is complete, the healthcare providers stop making the premium payments. This causes the insurance policy to lapse and leaves the patients with no healthcare coverage. Later on, the out-the-network providers bill the insurers for hundreds or even thousands of dollars towards the patients’ treatment. However, healthcare providers spend only a small amount on medical insurance premiums. The rest of the cost is borne by the consumers.

Gregory Pimstone of Manatt concludes by saying healthcare frauds are solely responsible for the exorbitant medical insurance costs. It is the consumers who are the primary sufferers and have to incur the ever-increasing healthcare expenses. This defeats the sole purpose of enacting the Affordable Care Act (ACA) in the first place. Fortunately, many states in America have necessary safety protocols to protect consumers from healthcare frauds and scams. However, they do not have sufficient manpower to properly monitor, evaluate and audit the extent of the offenses. If healthcare fraud continues to go on unabated, it is the consumers who will face the consequences.

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