Healthcare Fraud:
It is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment.
Examples:
It is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment.
Examples:
- Submitting claims for services not provided or used/Billing for a non-covered service as a covered service.
- Billing for services not rendered.
- Falsifying claims or medical records
- Misrepresenting dates, frequency, duration or description of services rendered
- Billing for services at a higher level than provided or necessary
- Falsifying eligibility
- Failing to disclose coverage under other health insurance
- Misrepresenting dates of service.
- Misrepresenting locations of service.
- Misrepresenting provider of service.
- Waiving of deductibles and/or co-payments.
- Incorrect reporting of diagnoses or procedures (includes unbundling).
- Over utilization of services.
- Corruption (kickbacks and bribery). False or unnecessary issuance of prescription drugs.
Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.
Examples of Abuse:
- A pattern of waiving cost-shares or deductibles
- Failure to maintain adequate medical or financial records
- A pattern of claims for services not medically necessary
- Refusal to furnish or allow access to medical records
- Improper billing practices
Below are the
15 types of medical billing fraud and abuse affecting the US healthcare system.
1.
Upcoding: Typically submitting a claim for a service more
severe than the actual service provided. For example, submitting a claim for a
broken ankle, when the patient was only treated for a sprained ankle.
2.
Cloning: Using an EHR system to automatically generate a more
detailed patient observation profile by copying from another patient’s file
with similar symptoms to appear as if a more thorough examination was done.
3.
Phantom Billing: Billing for services
never performed. This also affects healthcare costs in the millions of dollars
invested in tracking and prevention.
4.
Inflated Hospital Bills:
Gross overcharges for procedures and/or on equipment used on medical bills. For
example, $1,500 surgical screws or $500 Tylenol pills.
5.
Service Unbundling or Fragmentation:
Billing for multiple procedures separately, that should have been billed
together in a bundle in order to forgo the bundled rate and increase profit.
6.
Self-Referrals: When a provider
refers themselves or a partner provider to perform a service, usually for a
financial incentive.
7.
Repeat Billing: Billing twice for
the same procedure, supplies or medications.
8.
Length of Stay: Charges for days
not in the provider facility. Most hospitals will charge for the day you
arrived, but not for the day you left.
9.
Correct charge for type of room:
For example, if you were in a shared room, make sure you’re not being charged
for a private one.
10.
Time in OR: Some hospitals charge based on an “average” time
needed to perform an operation instead of the actual operation time.
11.
Keystroke Mistake: Entering incorrect
codes, resulting in significant overcharges or in some cases an undercharge.
12.
Cancelled Service: Occasionally a
medication, procedure or service that was prearranged and then canceled later
but is still charged.
13.
No Medical Value: Claims submitted
for payment for poor service that resulted in a decline in patient’s health.
14.
Standard of Care: Billing for
services in which the provider failed to meet quality standards of care and
provide preventative actions to safeguard patient’s health.
15.
Unnecessary Treatment:
When a provider performs unnecessary tests in order to bill for them.
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