What is health care fraud?
Health care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Fraudulent health care schemes come in many forms. Practitioner schemes include: individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit; billing by practitioners for care that they never rendered; filing duplicate claims for the same service rendered; altering the dates, description of services, or identities of members or providers; billing for a non-covered service as a covered service; modifying medical records; intentional incorrect reporting of diagnoses or procedures to maximize payment; use of (incompetent) staff; accepting or giving kickbacks for member referrals; waiving member co-pays; and prescribing additional or unnecessary treatment. Members can commit health care fraud by providing false information when applying for programs or services, forging or selling prescription drugs, using transportation benefits for non-medical related purposes, and loaning or using another’s insurance card.
When a health care fraud is perpetrated, the health care provider passes the costs along to its customers. Because of the pervasiveness of health care fraud, statistics now show that 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims.
Some examples of provider health care fraud are:
•billing for services not actually performed;
•falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary;
•misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery;
•upcoding – billing for a more costly service than the one actually performed;
•unbundling – billing each stage of a procedure as if it were a separate procedure;
•accepting kickbacks for patient referrals;
•waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan;
•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.
Some examples of consumer health care fraud are:
•filing claims for services or medications not received;
•forging or altering bills or receipts;
•using someone else's coverage or insurance card.