The majority of health care fraud is committed by a very small
minority of dishonest health care providers. Sadly, the actions of
these deceitful few ultimately serve to sully the reputation of
perhaps the most trusted and respected members of our society-our
physicians.
Unfortunately, the stock in trade of fraud-doers is to take
advantage of the confidence that has been entrusted to them in
order to commit ongoing fraud on a very broad scale. And in
conceiving fraud schemes, this group has the luxury of being
creative because it has access to a vast range of variables with
which to conceive all sorts of wrongdoing:
- The entire population of our nation's patients;
- The entire range of potential medical conditions and treatments
on which to base false claims; and
- The ability to spread false billings among many insurers
simultaneously, including public programs such as Medicare and
Medicaid, increasing fraud proceeds while lessening their chances
of being detected by any a single insurer.
The most common types of fraud committed by dishonest providers
include:
- Billing for services that were never rendered-either by using
genuine patient information, sometimes obtained through identity
theft, to fabricate entire claims or by padding claims with charges
for procedures or services that did not take place.
- Billing for more expensive services or procedures than were
actually provided or performed, commonly known as "upcoding"-i.e.,
falsely billing for a higher-priced treatment than was actually
provided (which often requires the accompanying "inflation" of the
patient's diagnosis code to a more serious condition consistent
with the false procedure code).
- Performing medically unnecessary services solely for the
purpose of generating insurance payments-seen very often in
nerve-conduction and other diagnostic-testing schemes.
- Misrepresenting non-covered treatments as medically necessary
covered treatments for purposes of obtaining insurance
payments-widely seen in cosmetic-surgery schemes, in which
non-covered cosmetic procedures such as "nose jobs" are billed to
patients' insurers as deviated-septum repairs.
- Falsifying a patient's diagnosis to justify tests, surgeries or
other procedures that aren't medically necessary.
- Unbundling - billing each step of a procedure as if it were a
separate procedure.
- Billing a patient more than the co-pay amount for services that
were prepaid or paid in full by the benefit plan under the terms of
a managed care contract.
- Accepting kickbacks for patient referrals.
- Waiving patient co-pays or deductibles for medical or dental
care and over-billing the insurance carrier or benefit plan
(insurers often set the policy with regard to the waiver of co-pays
through its provider contracting process; while, under Medicare,
routinely waiving co-pays is prohibited and may only be waived due
to "financial hardship").