6 Types of Healthcare Fraud

Healthcare fraud is not new, nor is it going away anytime soon. At the very least, however, it is possible to become educated on what constitutes healthcare fraud so to avoid committing it. Here are six common types of healthcare fraud.

1) Billing for services that were never given.

The services that are billed to an insurance company or the government should be reflected in the medical records of the patient. So, for example, if a doctor bills an insurance company for a patient visit on April 1, but there is no record in the patient’s medical file of such a visit, that raises many concerns. While there can be instances where the patient was seen, but no record exists due to miscommunication or administrative bungling, a pattern of this behavior can lead investigators down the road of fraud very quickly.

2) Billing for the wrong services.

An extreme example of this can be billing for open heart surgery on a patient who needed a minor procedure. One is obviously much more expensive than the other. And, while this example is not particularly plausible, it does illustrate the slippery slope that providers must handle when billing insurance companies and the government. Again, there is some wiggle room for providers who have coding errors due to administrative staff, but a pattern of this behavior calls into question if there is actually something more fraudulent going on.

3) Converting a non-covered service into a covered service.

Insurance companies and the government have a list of approved procedures and medications that are “covered” in that the company or government has approved it and will pay for its use. If a procedure or medicine has not been approved, then the insurance company or government will not pay for it. But what about an unapproved procedure or medication that is all of a sudden being coded as a covered procedure or medication? That is potentially fraud.

4) Not collecting copayments or deductibles.

If an insured patient has a copayment or deductible and their provider waives that fee, as in does not collect it, the complaint about this practice is not going to come from the patient. It’s going to come from the insurance company or government because this is money they end up spending to cover the extra costs that should have been covered by the insured themselves. In the end, everyone pays in the form of higher deductibles, rates, and taxes.

5) Overtreatment.

There’s a reason why women get annual exams covered once a year – they are designed to be annual. Insurance companies more often than not will not pay for a second annual exam during the year since this is overtreatment and possibly a different service being billed incorrectly. Some areas of medical services are goldmines of overtreatment fees, particularly drug and alcohol rehabilitation centers where patients never seem to quite get better and have to return several times for it to stick.

6) Bribery and kickbacks

On the scale of purposeful fraud, bribery and kickbacks reign supreme as the most blatantly fraudulent conduct. This kind of activity includes kickbacks for referrals and bribes for favorable treatment. The fraud is compounded when the kickbacks involve not only referrals of patients but billing for unnecessary services for those patients.

So, what is the best way to protect yourself, especially if you’ve been accused of healthcare fraud? Have skilled attorneys, like members of Weisberg Kainen Mark, on your side who understand healthcare fraud and can help you fight those charges. Call them today to get started.

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Written by Weisberg Kainen Mark, PL

Weisberg Kainen Mark, PL

Weisberg Kainen Mark, PL is a Miami-based law firm focused on providing comprehensive legal support to individuals and corporate entities caught up in tax controversies or charged with a criminal act. As experienced trial lawyers with a passion for justice, our firm provides clients with compelling advocacy, attorney availability, and creative solutions to your tax or criminal law matters.