From Medicare fraud to fake healthcare plans to phony claims, healthcare fraud and abuse is on the rise. The stories, cases, and facts are piling up, and they’re as real as they are horrifying.
For example, a doctor at a radiology clinic in Beverly Hills, California, recently settled a case for nearly $650,000 based on allegations that his clinic filed numerous false claims with Medicare for radiological tests that were unnecessary. In addition, the nonprofit anti-healthcare fraud and abuse watchdog Coalition Against Insurance Fraud states that approximately 60 percent of state healthcare fraud bureaus reported an increase in fake or fraudulent health plans in 2009.
But the healthcare fraud and abuse doesn’t stop there. The American Medical Association’s third annual National Health Insurer Report Card indicated that 20% of physician claims are processed inaccurately, costing $15.5 billion annually.
Healthcare fraud and abuse is indeed an industry unto itself. It’s so common, in fact, that it is estimated that healthcare fraud and abuse accounts for a whopping 10% of the United States’ annual healthcare expenditure, representing approximately $225 billion every year. Unfortunately, these numbers are growing each year.
What Are the Most Common Types of Healthcare Fraud and Abuse?
Healthcare fraud and abuse is rampant and occurs in many different ways. Some of the most common types of healthcare fraud and abuse committed by healthcare providers to defraud insurance companies, states, and the federal government include:
Billing for treatments never performed: Healthcare providers will often bill for services that were never provided by either using a real patient’s healthcare information or through medical identity theft to create or embellish claims.
Upcoding: This is a type of healthcare fraud and abuse where they falsely bill for a service that costs more than the service that was actually provided. In addition to healthcare fraud and abuse, this practice impacts patients by falsifying their medical records which can hinder them from obtaining insurance due to a nonexistent previous condition.
Performing unnecessary services: This healthcare fraud and abuse often occurs with diagnostic testing in which the doctor knows a test is unneeded but performs it anyway for the sole purpose of billing the insurance agency.
Misrepresentation: Typical in the world of plastic surgery, this diabolical healthcare fraud and abuse scam involves changing the name of an uncovered procedure to one covered by the insurance agency.
Falsifying diagnoses: By lying about a patient’s diagnosis to justify expensive tests, procedures, or surgeries, the scammer can be paid for unnecessary medical treatments.
Unbundling: By unbundling services provided, they can commit healthcare fraud and abuse by billing every aspect of a medical procedure as if it were a separate procedure.
Co-pay inflation: This type of healthcare fraud and abuse occurs when a patient is billed for more than his or her actual co-pay.
Kickbacks: In addition to accepting kickbacks from pharmaceutical manufacturers, some unscrupulous healthcare providers also accept kickbacks for patient referrals in order to provide unnecessary treatments and collect insurance payments.
Stop Healthcare Fraud and Abuse
Healthcare fraud and abuse statistics are alarming and growing every day, so payors and patients alike must be vigilant to prevent healthcare fraud and abuse. If you suspect that you’ve been a victim and you want to learn more, visit
www.TheIdentityAdvocate.com or call 310-831-4400.
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