This level of fraud is almost non-existent when there is NO insurance and NO universal healthcare. Anytime the person paying is not the one receiving service,

This level of fraud is almost non-existent when there is NO insurance and NO universal healthcare. Anytime the person paying is not the one receiving service, the appeal of fraud goes up. When the person paying is not paying with their own money the appeal goes up and a TON of incentives argue against finding fraud. At least in govt, there is sometimes a willful blind eye because finding fraud causes a huge headache and you don't benefit or get paid more. In fact, if you are taking an administrative fee to manage the program, reducing expenditures can hurt your own budget. I have traveled internationally where folks paid cash for services. It was a bit crazy - they would basically hold you hostage until you paid a bill / impound your car etc. BUT you could buy many drugs OTC (no DR visit even required) and the layers of things like approvals, pre-approvals, billing and billing codes etc simply didn't exist.