Unfortunately, Medicare fraud is nothing new and continues to exist. There are several fraud trends people should be aware of when using health care services. Most medical providers are honest and work hard to improve their patients’ health. Sadly there are also providers that want to illegally increase the size of their bank accounts. Let us together go through some of the basic health care provider schemes. Below are the 10 most common Medicare frauds.
Misrepresenting dates of service
Providers take advantage of the fact that each office visit is usually a separately billable service. So they might make more money by reporting they visited and treated the same patient on two separate days rather than one day. The services the fraudsters list on claim forms are actually provided. They simply put false dates because it is more profitable for them. You have to carefully check to assure that the patients’ medical file documentation matches the dates of service listed on the claim forms. It is important to focus on the date of service, not the date when they signed or submitted the claim. Those dates may be several days after the service was provided.
Billing for a non-covered service
This is also a very common type of Medicare fraud. Normally most patients are only concerned with two things: getting healthy or finding relief from their suffering. Secondly, it is how much they personally have to pay out of their own pockets for medical services. Because the insurance companies are footing the bills (or most of them), patients usually have no qualms as long as they are regaining their health.
Overutilization of services
Overutilization is mostly about billing for services that are not really necessary. Hypochondriac patients are the main victims of this scheme. Tests and exams can go on indefinitely or at least as long as a patient still has coverage or is able to make payments. Alcohol and drug rehabilitation facilities are ripe for overutilization.
Billing for services not rendered
Healthcare providers’ excuses for missing documentation are sometimes almost humorous. Some providers have blamed non-existing floods, fires, etc. Documents alone do not usually prove intentional wrongdoing. It is also necessary for fraud examiners and investigators to be able to locate witnesses who are willing to truthfully relate anything they know about the fraud. That is when well-planned interviews come into play. Unfortunately, sometimes patients have foggy memories of medical issues that impair their memories of past visits. And the claims might be several years old.
Most people in the medical field are honest and ethical, so fraud usually will bother their consciences. Sometimes they will just quit their jobs because they do not want to be part of illegal activities. But for those who remain on the job, they often will not tell what they know. Billings for services and care not rendered often make for simple cases to present in court because the scheme is so basic that even half-asleep jurors can understand it.
Misrepresenting locations of service
Most insurance companies do not accept self-injection as a reimbursable expense. Medical providers should monitor patients for several minutes after injections to ensure the patients do not have adverse reactions. There are cases when the physicians have billed for services provided in their offices that were located in the U.S. while the physicians were actually on overseas vacations.
Misrepresenting provider of service
Even though it is scary but it does happen that somebody might impersonate a physician and bill for treatment. There are numerous cases where medical doctors signed insurance claim forms showing that they had provided all the care. In reality, lesser-educated mental health professionals actually conducted the therapy. In these cases, the affected insurance companies would still have paid for the care that has provided the lesser-educated therapists (as long as they were licensed), but they would have paid less. Licensed clinical social workers are often reimbursed less than physicians.
There are also cases when a psychological care facility even hired people to be therapists who had never been trained to provide those services. The facility also had hired a part-time doctor to come to the office two days a week to review treatment files and sign claim forms.
Waiving of deductibles or copayments
Most government health care plans and insurance companies do not allow medical providers or facilities to waive patients’ deductibles or copayments. The rationale may be that if patients have to pay something to see doctors, they will only seek care if they really need it. It is also a way to offset some of the expenses. Regardless, some providers do waive patients’ deductibles or copayments and then submit other false claims to insurance companies to make up the dollar difference. Some of the providers will also add a bunch of other false services to the claim forms. The aim is to increase their illegal gains. They know that the patients might complain because their co-payments and deductibles were waived. So, of course, it is beneficial to interview patients plus current and former medical facility employees.
Incorrect reporting of diagnoses or procedures
Sadly some unscrupulous providers can bill for extra services if they report false serious diagnoses or procedures performed. A crooked provider could initially misdiagnose with head trauma an elderly patient who happened to fall inside a nursing home. This would require the use of a computed tomography or blood tests which are unnecessary in this case. Of course, some diagnoses require longer, more expensive hospital stays. Unbundling (when a provider charges a comprehensive code plus more component codes) is one of the most often incorrect reporting of procedures.
The potential for corruption in the healthcare industry is great. Providers unlawfully pay for and receive payment for referrals. Obviously, that practice can lend itself to abuse when referrals are made for services that are not even needed, such as X-rays, MRIs, prescription drugs, etc. Sometimes the kickbacks or bribes are hidden or disguised in the form of luxury vacations, discounts on facility rentals or hidden gifts as compared to just slipping a check or cash under the table.
False or unnecessary issuance of prescription drugs
Prescription drug abuse is sometimes defined as taking prescription medication (prescribed or not) for reasons beyond physicians’ intentions. They most commonly abuse the painkillers. These drugs’ street value is almost 10 times the legal prescription value.
Some patients “doctor shop” to obtain drug prescriptions and especially painkillers. The doctors usually have no idea that the patients have already visited other physicians to obtain the same or other drugs. Fraudsters can easily recover the cost of the doctors’ visits by selling some or all of the drugs on the street. Some patients and even medical facility employees steal prescription paper pads and forge prescriptions and provider signatures. Others make pen-and-ink changes to the quantity and/or authorized refill numbers on the paper prescriptions.
These were the 10 most popular Medicare frauds. Hopefully, the situation will not last forever. Stay healthy and good luck.