The Healthcare Fraud and Abuse Review reported that it recovered $2.6 billion in health care fraud from American health care companies. Health care fraud has led to significant losses from Medicaid, Medicare, and other private insurance companies.
Health care fraud, however small, has considerable adverse impacts on everyone’s health benefits. It is essential to know more about health care fraud and how to avoid it.
If you’re not familiar with health care fraud, you’re in luck. Keep reading our guide to know more about health care fraud and how to protect yourself.
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What Is Health Care Fraud?
Fraud in healthcare refers to a crime committed when dishonest consumers submit misleading information,. This information is then used to determine the payable health care benefits. People tend to misstate information about the nature, scope, or type of the medical service provided.
Hospitals and physicians perpetrate most of these healthcare fraud cases. The type of fraud committed in this case is often fraudulent billing. There are several other health care frauds that you might have been a victim of without your knowledge.
Types of Health Care Fraud
The number of possible health care frauds are inexhaustible. Here are some of the typical health care fraud schemes that you need to know;
Billing for Non-Covered Services As Covered
Non-covered services refer to medical services, which aren’t reimbursable by private insurance or the government. Some providers will try to get reimbursement for non-covered services by listing them fraudulently as covered services. For instance, a plastic surgeon who performs a non-covered cosmetic procedure then bills it as covered is committing a health care crime.
Patients hardly pay attention to the billing. Their main concern is recovery and the out-of-pocket expenses that they incur. Some health care providers might take advantage of the situation to include services that shouldn’t be part of the covered services.
Double billing is a scheme whereby a provider lists the same services more than once, leading to double payments. For government covers, some providers can include the same services multiple times for more costs. Some of these providers tweak the dates they provided the services, name of the patient, and description of diagnosis and treatment.
It’s not surprising to find healthcare providers who bill private insurers and the government for the same services. With some patients having private and government health covers, double billing has become a common health care fraud that you should know.
If you’re a medical practitioner, you should be careful not to double-bill erroneously as you might be faced with a case of health care fraud. You’ll need white collar defense for you to win such a case. With the right health care fraud lawyer, you can prove that the double bill was not intentional.
Billing for Unrendered Services
Billing for unrendered services ranks as one of the most common healthcare fraud types. The fictitious services scheme refers to the billing of medical services that patients didn’t receive. It can involve fake or actual patients.
Some health providers create fake profiles of patients by purchasing or stealing personal information of real patients. They list them as their patients and bill them as though they received medical services.
It is easier to detect this kind of fraud than others. The supposed patient’s file might have conflicting information. The Health Fraud Agency should have a regular review of the documentation to verify that everything indicated on the documents isn’t fabricated.
The estimated Medicare and Medicaid fraud is $60-$90 billion. A part of this money is lost through unbundling. Improper coding can occur through unbundling, which refers to billing services separately instead of bundling them together as a single procedure.
Medicaid and Medicare have lower rates for some group procedures, such as surgeries and incisions. Providers who fragment the bill increase their profit margin, which is illegal.
Health care providers should report if their institution has been practicing unbundling. If you’re a whistleblower, the False Claims Act will protect you, and you won’t need to worry about retaliation. Besides, whistleblowers may get rewards from the government, which can be as high as 30%, depending on the recovered amount.
Misrepresenting Service Providers
Impersonating physicians is a health care fraud that often takes place in specialists’ clinics. It’s not surprising to find a medical doctor who has signed the insurance forms as the physician who attended a patient. Yet, the task was delegated to a person with fewer skills or knowledge in the area.
Some healthcare facilities have a part-time doctor who only comes in like two times a week to review patients’ files as they sign the claim forms. These physicians hardly confirm if the people attending to the patients have the licenses for the therapies.
Health Care Fraud Prevention
As a patient, you can protect yourself by asking questions about the treatments you receive and their cost. Question promotions and advertisements that offer free services, treatment, and tests. Being inquisitive will save you from several plausible health care frauds.
It is also essential to be keen when filling out the claim. Deal with one form at a time, as being presented by many documents at a go can overwhelm you. You also need to be careful when disclosing any insurance information.
If you suspect any fraudulent activity, report to Special Investigations. You’ll be saving yourself and millions of Americans who struggle to meet their health care needs.
Health Care Fraud Has Been a Challenge in the U.S. Health Sector
The list of health care schemes is inexhaustible. Fraudsters keep devising ways of getting the money in the health industry. It is essential to understand the different types of health care fraud, as it will help you protect yourself.
Health care fraud has significant adverse impacts on individuals and the economy. You need to know how to identify these cases and prevention measures.
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