Question

Health Care Fraud

Your mission is to research health care fraud as many innocent people as victims of fraudulent health care adverting.  

Do a web search for "health care fraud".  

Choose a topic/article of your choice.

Read the article, summarize your findings and post a short summary.

Answer 1

Health care provider Fraud schemes:

1. Misrepresenting dates of service

Providersmight make more money by reporting they visited with or and treated the same patient on two separate days rather than one day. Each office visit is usually considered a separate billable service . Often the services the fraudsters list on claim forms are actually provided, but the dates are false because its more profitable for the providers.

So check to assure that the patients medical file documentation matches the dates of service listed on the claim forms

Focus on the date of service not the date the claim form was signed or submitted because those dates may be several days after the service was provided

2. Corruption (kickback and bribery)

Like all industries , the potential for corruption in the health care industry is great . Providers have been known to unlawfully pay for and / or receive payments for refferals. Obviously that practice can lend itself to abuse when referals are made for services that are not even needed such as X rays , MRI's , prescription drugs etc.

To prove a bribery kickback scheme, you must establish quid pro quo. Substantiating that the provider paid or received something of value in return for referrals is paramount and not very easy to do. Sometimes the kickbacks or bribes are hidden or disguised in the form of luxury vacations, discount on facility rentalsor hidden gifts as compared to just slipping a check or cash under the table. I investigated one provider who made inflated office rental payments to another physician to disguise his kickbacks for referring patients to him.