Scientific Fraud

T he first time I came across the situation of an employee of a group physician practice being admitted to the hospital owned by that practice for a slip-and-fall accident on a monthly basis amazed me. I was horrified to discover that the employee had 30 to 40 active insurance certificates, including health insurance, accident insurance, workers’ compensation, and automobile personal injury policies. This spurred my interest in the subject of medical fraud and insurance fraud involving medical providers. From the standpoint of fraud investigation and fraud control medical fraud poses an interesting dilemma. On one hand, it is seldom self-revealing, and, on the other hand, it is best considered as a spectrum. The spectrum ranges from, as a former chairperson of the American Medical Association Council on Ethics and Judicial Affairs once said, "Physicians don’t commit fraud; they may merely shade the truth, when..." to a systemic looting of the healthcare system," as evidenced by the Los Angeles physician and his brother who billed for more than $1 billion of services that were never rendered. The fundamental differences between fraud investigation and fraud control rest on one’s perception of whether the bigger problem is one of known fraud or unknown fraud. In the case of self-revealing fraud, such as credit card fraud, the extent of the fraud eventually becomes known. Certain methods are used to investigate the fraud, and, in fortunate situations, the perpetrators are stopped and made to recompense the aggrieved parties. Sparrow1 indicates that medical fraud, on the other hand, is much more complex and in most circumstances unknown. Indeed, there are 3 foci, namely the patient, the payer, and the medical provider. The common objective of the fraud is generally to obtain money. As the editor of a scientific journal one is particularly concerned about scientific fraud. When one asks oneself about the nature and extent of the fraud, whether it should be regarded as known or unknown, who is potentially involved, and what their objectives, incentives, and motives are, it is evident that scientific fraud is considerably more complex than medical fraud and insurance fraud involving medical providers. Although there is no commonly agreed upon definition of scientific fraud, the deftnition of health insurance fraud used in the Medicare carrier’s manual could serve as a model: "An intentional deception or misrepresentation which an individual or entity makes, knowing that the deception could result in some unauthorized benefit to the individual the entity or some other party." We simply cannot rely on the working definitions that most academic institutions use, that is, "I know it when I see it," as US Supreme Court Justice Potter said in 1964 when he tried to define sexual obscenity. Three particular areas of potential fraud with which we, as editors, must deal are the deliberate use of incorrect data and statistical methods, the absence of information about