How to Spot (and Avoid) Healthcare Fraud
Health care fraud is a severe problem that affects us all. It costs tens of billions each year and can raise health insurance premiums, expose you to unnecessary medical procedures, increase taxes, or even land someone in jail as one of the penalties.
Health care fraud is a severe issue in the medical industry that can come from any person or organization. It’s committed when providers, patients, and others, trick the healthcare system into thinking they provided services when really nothing was done. This results in funds being spent on unnecessary things, like insurance claims that drive up costs for everyone who has access to these treatments through their insurer. A doctor could bill patient visits even though there was no diagnosis registered, known as Medicaid billing abuse. This behavior may seem minor until you consider how many lives are affected each year because people submit false reports trying to get rich off others.
In addition to financial costs, healthcare fraud can also have serious personal consequences. Patients may be subjected to unnecessary and potentially dangerous treatments, and they may be put at risk if their insurance coverage is suddenly canceled due to fraud.
Although health care fraud is a severe problem, there are steps that you can take to protect yourself. If you suspect that someone is committing fraud, you should report it to your state insurance department or the Department of Justice. We can help root out this costly and dangerous crime by working together.
What does health care fraud look like?
Fraud Committed by Medical Providers
Medical providers are committing fraud with their billing practices by submitting double the amount of claims for services that happened. Phantom billing occurs when patients receive bills for supplies or visits they never received, and unbundling is when there’s more than one bill submitted per claim number on your health insurance form. Upcoding often happens with drugs, charging higher prices than what was initially prescribed despite no change being needed.
Fraud Committed by Patients and Other Individuals
Fraud committed by patients and other individuals is a severe problem in the healthcare industry. Bogus marketing, identity theft, and impersonating healthcare professionals are all ways that fraud can be perpetrated.
Bogus marketing often convinces people to provide their personal information, such as their health insurance ID number. This information can be used to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan.
Identity theft and identity swapping are serious problems in healthcare. Identity theft occurs when someone uses another person’s health insurance without permission. This can lead to false claims, and the individual may not realize their identity has been stolen until they receive a bill for services they did not receive. Identity swapping is similar, but it involves two people using each other’s insurance.
Fraud Involving Prescriptions
Fraudulent activities involving prescriptions can take many forms. Forgery creates or uses forged prescriptions, while diversion entails diverting legal prescriptions for illegal uses, such as selling one’s prescription medication. Meanwhile, doctor shopping entails visiting multiple providers to get prescriptions for controlled substances or from medical offices that engage in unethical practices. These activities can have serious consequences, both for the individual engaging in them and for society at large. Prescription fraud is a severe problem that must be addressed through education and awareness-raising initiatives.
How can healthcare fraud and abuse be prevented?
First and foremost, stay on top of your health history. Be aware of what tests you’ve had or a diagnosis that might be relevant to the care being given by a doctor; make sure those records accurately reflect such things too.
Keeping an accurate journal is also very helpful for future doctor visits. If there are any discrepancies between your medical file with other databases like claims processing systems, then it could result in inappropriate treatment.
If your doctor orders a test or procedure you aren’t convinced, you need to ask questions. Get a second opinion, if necessary, but always make sure you understand why a given test or treatment is being recommended.
In addition, don’t hesitate to question excessive charges on your health care bills. If something doesn’t seem right, call and ask for an explanation. By staying informed and being proactive, you can help protect yourself from becoming a victim of healthcare fraud.
If you are facing healthcare fraud, it is in your best interest to hire an experienced healthcare fraud lawyer. Your attorney will know how to analyze the case against you and determine the best legal strategy. Your lawyer can also explain the different legal options available to you, including pleading guilty, going to trial, or appealing the case. If you decide to go to trial, your lawyer can represent you in court and file all the necessary legal paperwork on your behalf. If you are not happy with the outcome of your case, your lawyer can also file an appeal. Hiring a healthcare fraud lawyer gives you the best chance of achieving a favorable outcome in your case.