Health care fraud encompasses health insurance fraud, medical fraud, and drug fraud. Health insurance fraud can occur when an individual or a company defrauds a government health care program (i.e., medicare) or an insurer. Health care fraud is known as a white collar crime in which individuals or groups file health care claims dishonestly in order for themselves to receive monetary gain. The methods in which health care fraud is done differ as individuals who engage in health care fraud are usually finding new ways to accomplish fraud. The money and other damages that are incurred by fraud can be recovered through the use of the federally mandated False Claims Act. According to the Federal Bureau of Investigations (http://www.fbi.gov), health care fraud costs tax payers in the United States of America $80 billion each year. In 2010, $2.5 was recovered through litigation involving the False Claims Act. Also in 2010, individuals (i.e., whistleblowers) reporting health care fraud were paid approximately $307,620,400 for their efforts in reporting health care fraud.
A large amount of health care fraud is conducted by organized crime syndicates as well as a minority of health care providers who are dishonest. Common types of health care fraud include the following:
– Billing for services not rendered: This occurs when patient information is used to fabricate claims or through padding of claims with charges for services or procedures that did not occur.
– Upcoding: This occurs when someone bills for more expensive procedures or services than the services that were actually administered or provided. This often requires the provider to change the patient’s diagnosis to a more serious condition in order to inflate the price of the procedure they are claiming.
– Provision of unnecessary services: This occurs when a provider performs unnecessary services in order to generate higher insurance payments.
– Misrepresentation of treatments that are not covered as medically necessary treatments in order to obtain insurance payments. This is often done in cosmetic surgery fraud. In cosmetic surgeries, sometimes non-covered cosmetic procedures (i.e., nose jobs) are billed to insurance companies as medically necessary (i.e., repair to deviated-septum).
– Falsification of a patient’s diagnosis in order to justify tests that are not needed, surgeries, or other procedures that are not necessary.
– Unbundling: Billing insurance each step of a procedure, making it seem that each step was a separate procedure.
– Billing a patient an amount that is more than the co-pay for services that are already paid for by the insurance company under the terms of the contract.
– Kickbacks: Accepting kickbacks for referrals of patients.
– Waiving patient deductibles or co-pays for dental or medical care and over billing the benefit plan or insurance company.
There are several ways in which an individual can report cases of fraud. If an individual or health care provider suspects they have witnessed a case of health care fraud, they should contact the Federal Bureau of Investigation by contacting their local office, online tips form, or by telephone. Individuals who suspect or are the victim of fraud should contact an attorney for consultation in order to ensure that the government actively pursues the fraud claim. Attorneys that are experienced in litigation regarding the False Claims Act should be contacted for consultation. An attorney that specializes in fraud and the False Claims Act can advise individuals of their protections, rights, and what evidence they must have to create a solid case against the group or individual who has committed the alleged health care fraud. Individuals who are convicted of health care fraud can receive serious consequences including fines, incarceration, and may lose the right to practice medicine indefinitely.
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