HealthCare Fraud in the medical field is illegal. It occurs when a dishonest provider or customer knowingly provides incorrect or misleading information or encourages another person to determine the amount of health care benefits owed.
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What is HealthCare Fraud?
Most criminal statutes define Healthcare Fraud as intentional deception done for illegal benefit as a federal offense. When the knowing intent to obtain an illicit advantage cannot be proven, Healthcare Scams are a comparable action or behavior. Healthcare fraud and abuse instances include:
- false representations of supplied products or services
- using another person’s health insurance information to get goods or services
- falsifying signatures or medical documents to support services or goods that aren’t what claim to be
- separating services from a group to boost medical payments illegally
- misrepresenting the place where goods or services are delivered
- unlicensed medical care provision
- submitting duplicate claim forms
What are Common Types of HealthCare Fraud?
First, let’s define what fraud, waste, and abuse are. Careless actions that violate best clinical procedures and divert funds away from treatment are known as waste and abuse, although they are not always carried out with malicious intent. Contrarily, fraud is an intentional lie or false statement to obtain unrequested advantages. Payers need to be alert to several all-too-common kinds of Health Care Fraud.
Billing for goods or services that aren’t delivered – This is a clear-cut and deliberate action by a healthcare professional. This widespread type of Healthcare Fraud is one method that clinicians can dishonestly divert money away from patient care and into their own pockets. Medicare fraud Examples include charging for patient appointments that never took place or for medical devices that the doctor did not give. For instance, a Belgian orthopedic material producer was found guilty of falsifying prescriptions to increase the number of knee braces it could charge for last year.
Upcoding is the practice of health care professionals billing for more sophisticated and expensive goods and services than those delivered. It can occur accidentally, such as when a provider inputs the wrong code but frequently results from deliberate fraud. The producer of medical equipment created a gadget that could be used with either a cheap, noninvasive operation or a more involved, pricey one.
- Unbundling –
Similar to upcoding, unbundling is submitting invoices piecemeal to maximize reimbursement for tests or operations that should be invoiced together and at a lower cost. A hospital lab, for instance, would run a patient’s blood through a panel of tests. The lab may attempt to maximize its revenue by paying for each test separately rather than for the entire board.
- Providing unnecessary services –
Healthcare practitioners doing needless operations on patients against their will to profit financially is perhaps the most egregious Example of Health care fraud. One doctor was sentenced to 45 years in jail in 2015 for giving chemotherapy to cancer-free, healthy people. To pay for his therapy, he had illegally obtained 17.6 million from healthcare payers, putting dozens of lives in peril. The majority of instances of this type of fraud are not as egregious. For example, when a surgeon advises knee surgery rather than first considering less intrusive choices like treatment, it seldom makes headlines. However, this pervasive, low-level fraud depletes healthcare budgets and hurts people. Doctors execute thousands of medically unnecessary procedures yearly, a severe breach of trust and a significant source of wasteful expense.
- Doctor shopping-
In which people visit many doctors to receive multiple doses of restricted medications is a consequence of the overuse of prescription painkillers in the United States. Either the patient abuses these medications excessively or is unlawfully transferred to others. Opioids murdered more than 33,000 individuals in the US in 2015, the worst year on record. Prescription opioids were implicated in over half of all opioid overdose deaths. Addiction to pharmaceutical opioids is on the rise even in Europe. Both dishonest patient conduct and negligent prescribing practices by doctors are partially connected to the widespread use of prescribed opioids. While some providers use procedures to stop patients from going to several doctors, others do not.
- Medical identity theft –
The healthcare sector has benefited dramatically from digitizing personal health information (PHI), which has led to better services and more efficiency. It has, however, increased the potential of theft of PHI. An all-too-common crime is fraudulently using someone else’s medical identity to gain healthcare supplies, services, or money. The number of medical identity theft instances in the US increased by 21 percent last year, with victims paying an average of 13,500 to remedy each incidence.
How does a HealthCare Scam Work?
The Medical Fraud scheme we witness preys on individuals through door-to-door solicitations, SMS messages, social media posts, and telemarketing calls. A common tactic is to pose as a government organization, the health department, a group of doctors, or a health insurance provider to capitalize on people’s concerns.
Medicare Fraud may take many different forms. Include making unsubstantiated or fraudulent claims about a treatment or medication, phony excuses for contacting someone, and attempts to sell items that do not need to be paid for (such as vaccines).
How to Identify HealthCare Fraud?
- Falsifying medical necessity certificates and charging for services that are not medically essential;
- Separate billing for services that ought to be covered by unified service prices;
- Falsifying treatment plans or medical records to obtain reimbursement;
- Exaggerating diagnoses or treatments to increase payments;
- Fabricating charges or payment entitlements in cost reports; and
- Asking for “kickbacks” in exchange for various goods or services.
How to Avoid HealthCare Scams?
- Go Slowly:
Spend some time researching any individual claiming to be affiliated with a firm that offers health benefits, an insurance provider, or a corporation that provides health insurance. Any legitimate business, service, or government representative won’t press you for an immediate response and will supply you with further information about them if you inquire.
Give only your health care provider or insurance company access to your personal information, including name, address, social security number, credit card number, etc.
- Protect Your Privacy:
Be cautious while sharing personal information on social media. Scammers will try to discover it on Facebook and other websites to deceive you into giving them both money and additional private information.
- Continue Your Education in Healthcare and Disseminate Your Knowledge:
Scammers constantly seek new methods to obtain your money and personal information. Keep yourself and your family educated on how to avoid falling victim to these frauds.
How to Protect Against HealthCare Fraud?
Use these simple methods to safeguard yourself from medical fraud and keep overall health care expenditures low:
- Like a credit card, keep your health insurance identification card safe. A health insurance card can be used as a license to steal in the wrong hands. Never provide your policy number to a door-to-door salesperson over the phone, online, or the phone. Be cautious while sharing your insurance information, and notify your insurance provider immediately if you misplace your insurance ID card.
- Declare fraud. Call your insurance provider immediately if you think you could be a victim of Health Insurance Fraud.
- Read the advantages and policy declarations. Read your policy, the EOB statements, and any other documentation you get from your insurance provider. Are the service dates shown on the forms accurate? What about the services that were listed and invoiced for rendering?
- Do not accept “free” offers. It’s likely a false advertisement. Free health care services, tests, or treatments are frequently part of fraud schemes that fraudulently bill your insurance provider and you for thousands of dollars in procedures you never had.
What to do if you Lost your Money to HealthCare Fraud?
The Federal Trade Commission lists the following warning flags to watch out for if you believe that Health Insurance Scam defrauded you:
Examples of Health Insurance Fraud
- getting a fee for a service or piece of equipment you never used
- being contacted by a medical debt collection agency
- observing unauthorized medical expenditures on your credit report
- noticing discrepancies between your insurance company’s description of benefits and the actual services and office visits you received
- abruptly using up all of your insurance benefits
- having phony medical problems lead insurance coverage to be refused
Contact Financial Fund Recovery if you have lost money to HealthCare fraud, and we’ll get back in touch with you and help recover your funds.