Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 13

Product, Service, and Consumer Market Activity

We must rapidly begin the shift from a “thing-oriented” society to a “person-oriented” society. When machines and computers, profit motives, and property rights are considered more important than people, the giant triplets of racism, materialism, and militarism are incapable of being conquered.

–Martin Luther King, Jr. (1929–1968)

Product market activity (PMA), service market activity (SMA), and consumer market activity (CMA) compose the business side of healthcare. The PMA, SMA, and CMA perspective helps separate the human side of healthcare. How else can the mind rationalize providing invasive procedures to another human being with full knowledge that the service was not necessary? How can a dentist pull healthy teeth from a child? How can a surgeon perform life-threatening surgical procedures with no basis?

Likewise, how can a claims system process deny a procedure that is necessary to sustain the patient’s life prior to the completion of the appeals process, therefore making the long-term costs a moot issue? If we walk further down the pipeline of the benefit plan, how can decisions be made on eliminating benefits based on the need for cost savings alone? What if money simply does not exist, or the expense of services will not allow for profit shareholder expectations? It is the “thing”-oriented side of healthcare versus the “people” side that often drives the ethically challenged to cross that line in pursuit of profits. ...