The majority of healthcare fraud is committed by a small minority of dishonest healthcare providers with the only “red flag” for the government being the aggregate dollar amount. (remember, a medical degree does not confer honesty). Providers who engage in fraud and abuse are subject to sanctions under a number of federal and state laws whose penalties range from monetary fines and damages to prison time and exclusion from the federal healthcare programs, including Medicaid.
Within the current healthcare system, many factors help these dishonest providers cover up their wrongdoings. These factors include:
- The sheer size of our nation’s population.
- Hundreds of medical conditions and treatments on which providers can base false claims.
- Healthcare consumers who blindly trust their providers and who have little opportunity to manage their care.
- Ability to spread false charges across multiple insurers simultaneously without being detected.
The most common types of fraud include:
- Billing for services never rendered.
- Upcoding, or billing for more expensive services or procedures, than those that were actually performed.
- Performing medically unnecessary services solely for the purpose of generating extra insurance payments.
- Misrepresenting non-covered treatments as medically necessary.
- Falsifying a diagnosis to justify tests, procedures or surgeries.
- Unbundling, or billing each step of a procedure as if it were separate.
- Billing a patient for more than a co-pay for services prepaid or paid in full by the insurer.
- Accepting kickbacks for patient referrals.
- Waiving patient co-pays or deductibles and overbilling the insurance carrier or benefit plan.