Signs Your Doctor or Pharmacist May Be Committing Fraud

Signs Your Doctor or Pharmacist May Be Committing Fraud

Going to the doctor or getting a prescription filled is supposed to help us get better when we’re sick or injured. But sometimes, healthcare providers abuse their positions of trust and commit fraud, putting their own financial gain above their patients’ health. Here are some signs to watch out for that your doctor or pharmacist may be engaged in fraudulent activities:

Doctors

• Ordering excessive or unnecessary tests, especially expensive ones
• Billing for services not provided
• Upcoding – billing for more complex services than were actually delivered
• Prescribing medications for off-label uses that may not be medically necessary
• Receiving kickbacks for patient referrals or prescriptions
• Waiving copays or deductibles without cause
• Misrepresenting non-covered treatments as medically necessary
• Falsifying diagnoses to justify tests or procedures
• Billing for appointments that never happened
• Using stolen patient information to submit fraudulent claims
• Ordering excessive home health care services

Some things to look out for are if your doctor orders many tests but never seems to follow up on the results or if they prescribe medications too quickly without fully examining you. Billing for appointments you missed or don’t remember is also a red flag. Any time a doctor says one thing is “free” or doesn’t charge your copay, it could signal illegal waiving of costs.

Pharmacists

• Billing for prescriptions that were never filled
• Billing multiple payers for the same prescriptions
• Billing for more expensive medications than were dispensed
• Billing for brand name drugs when generics were provided
• Billing for prescriptions that were not medically necessary
• Falsifying records to show prescriptions were filled that were not
• Prescribing medications without a valid prescription from a provider
• Dispensing expired or adulterated prescription drugs
• Providing inducements to patients to fill prescriptions at their pharmacy

Look out for pharmacies that waive copays or overcharge insurance. Also be wary if you’re receiving medications you didn’t actually have prescribed or if the pharmacist adds refills without contacting your doctor first. Filling prescriptions at odd hours when oversight may be lower is another potential warning sign.

How Healthcare Fraud Occurs

Doctors and pharmacists have access to a huge money pool in public and private health insurance funds. Unfortunately, a small minority abuse this system for profit. Some common healthcare fraud schemes include:

• Upcoding – Billing for more expensive services than provided
• Unbundling – Separately billing for services that should be a single fee
• Kickbacks – Doctors referring patients to a pharmacy or lab that pays them a cut of the profit
• Identity theft – Using stolen patient info to file false claims
• Prescription diversion – Selling prescriptions to drug dealers or abusers

Often, these schemes involve referring patients for unnecessary services or billing multiple insurers for the same procedures. Some criminals set up sham clinics or pharmacies specifically to generate fraudulent claims. Organized crime rings will also get people fake IDs to use at different doctors to obtain multiple prescriptions for controlled substances, which are then sold illegally.

Effects of Healthcare Fraud

Healthcare fraud doesn’t just hurt insurance companies and government programs like Medicare and Medicaid. Patients suffer too. Effects of healthcare fraud include:

• Higher insurance premiums and out-of-pocket costs for consumers
• Higher costs for taxpayer-funded programs like Medicare
• Overtesting, overtreatment or mistreatment due to financial motives
• Privacy violations through use of stolen patient data
• Diversion of prescription drugs to illegal markets
• Loss of trust in doctors and pharmacists

Ultimately, healthcare fraud undermines the doctor-patient relationship. It erodes public trust and faith in the medical system. Ethical providers suffer from the stigma as well. Stopping fraud helps protect patients physically and financially.

How to Report Suspected Healthcare Fraud

If you believe your doctor, pharmacist or other healthcare provider is engaged in fraud, here are some steps to take:

1. Document your concerns – Keep records about your appointments, prescriptions, bills and other details.
2. Check your medical records – Request copies to verify their accuracy.
3. Talk to your insurance company – They can investigate suspicious claims.
4. Report the provider to the authorities – Contact agencies like the FBI, DOJ or HHS Office of Inspector General.
5. Consult a whistleblower attorney – There may be protections and rewards for reporting fraud.
6. Choose a new provider – Find an ethical doctor or pharmacy you can trust.
7. Monitor your credit – Fraud often involves identity theft, so check for any suspicious activity.

Also, talk to your state medical board or pharmacy board about disciplinary actions. You can look up providers in the National Practitioner Data Bank. Reporting fraud early can prevent more patient harm and financial losses down the road.

Recent Healthcare Fraud Cases

Several major healthcare fraud cases have made headlines recently:

• In Houston, a physician and two pharmacists were charged in a $170 million kickback and money laundering scheme.
• The DOJ convicted two Michigan pharmacists of a $145 million fraud scheme involving opioids.
• A physician in Nebraska was sentenced to prison for fraudulent billing practices.
• In Florida, a pharmacist was convicted of a $4.3 million Medicare scam.

These cases involved millions in false claims, kickbacks for referrals, and identity theft to defraud insurers or taxpayers. The ringleaders face serious penalties like prison time and having to repay their ill-gotten gains. But many smaller frauds go undetected. Patients must stay vigilant about signs of potential healthcare fraud.

How to Choose an Ethical Provider

To find a trustworthy healthcare provider:

• Ask people you trust for referrals.
• Research a doctor’s credentials and background.
• Look for reviews, but beware fake ones.
• Visit the office to judge professionalism.
• Interview the doctor and ask lots of questions.
• Verify board certification and state licensure.
• Check for disciplinary actions or malpractice claims.
• Go with your gut feeling about the provider.

Also, choose doctors who take time to explain things to you and seem to care about more than just money. For pharmacies, look for well-trained pharmacists, clean organized stores, and good customer service.

Protecting Yourself from Healthcare Fraud

Here are some tips to avoid becoming a victim of healthcare fraud as a patient:

• Review all bills and statements for errors.
• Don’t accept waivers for copays or deductibles.
• Ask about less expensive medication options.
• Get a second opinion for major procedures.
• Verify with your insurer if something seems suspicious.
• Keep records of your appointments, tests and prescriptions.
• Monitor your credit report and statements for identity theft.
• Educate yourself on your conditions and treatment options.

Staying informed and proactive helps deter fraud. You know your health history best. If a provider recommends care that seems excessive or you’re unsure about, check with your insurance company or get a second professional opinion. Protecting your health includes protecting against fraud.

Healthcare fraud often goes unnoticed, but it’s important to speak up if you think it’s occurring. This protects other patients and prevents further financial losses. Choosing an honest, ethical provider is key to avoiding this issue. With vigilance, we can maintain trust in our healthcare system.