Health Care Fraud
The General Accounting Office estimates that tens of billions of tax dollars are lost to Medicaid and Medicare fraud every year.
While the vast majority of medical professionals and other health care service providers are honest and ethical, there are some who intentionally falsefy or misrepresent a health care procedure provided to a patient in order to cheat Medicare, Medicaid, or private insurance companies. What Does Health Care Fraud Look Like?
Health care fraud may involve billing for services that were not provided. A health care provider may intentionally assign the wrong code to a procedure, using a code for a different procedure that is reimbursed at a higher amount. This is called "up-coding." Sometimes health care fraud is done through billing for non-covered services as covered services or billing for medical equipment that was either never received by the patient or was returned to the provider. Charging for services separately that are normally charged together (called "unbundling") is another form of health care fraud. A health care provider may also commit fraud by billing for medical procedures over a period of several days when the treatment actually occurred during just one visit.
How To Prevent Health Care Fraud
Follow these tips to reduce the risk of health care fraud:
Report any errors, suspected fraud or abuse. Call the SMP Fraud Helpline at 1-888-967-9100. What Is NOT Health Care Fraud?
Only intentional misrepresentations are fraudulent. Honest mistakes by the provider are not. Other things that are not necessarily fraud include:
If you suspect fraud, contact the health care provider first and inquire about the suspicious item(s). More often than not, the provider can explain the charge to you or correct an honest mistake.
Types of Health Care Fraud
Ambulance Fraud Ambulance fraud occurs when a company transports a patient and then bills Medicare knowing that the patient did not qualify for this type of service. Another form of ambulance fraud occurs when the ambulance transports multiple patients at the same time, but bills for individual trips. An unscrupulous ambulance company may bill for advanced life support when only basic life support was provided. Power Wheelchair and Scooter Fraud Doctors, or those representing themselves as doctors, sometimes prescribe equipment that an elder may not need. Suppliers of durable medical equipment may commit fraud by intentionally failing to pick up equipment an elderly person or other vulnerable adult no longer needs and continue to bill Medicare for the equipment. Sometimes scam artists will obtain Medicare numbers from vulnerable elders through coercion or deceit in order to bill Medicare for equipment that is never delivered. Wheelchair and scooter fraud also occurs when suppliers bill for the most expensive power wheelchair or scooter, but provide a cheaper model to the patient. Prescription Drug Scams The new Medicare Part D prescription drug plan has unfortunately created new opportunities for con artists to cheat older victims. Fake companies contact elders pretending to be representatives of Medicare or private companies selling prescription drug plans. The caller may request a checking account number to enroll the person in a Medicare prescription drug program. Often, the perpetrator asks for a certain amount of money, usually $299.00 (sometimes referred to as the "299 ring"). It is ILLEGAL for Medicare drug plan providers to ask for payments over the phone or by email. If you or someone you know has received a call like this, notify local law enforcement. You can also call the SMP Fraud Helpline at 1-888-967-9100. Beware also of dishonest pharmacies that may give a customer fewer doses of medication than prescribed, but charge the elder and/or Medicare the full amount. This is called "short pilling." Check your prescriptions to make sure you received the full amount, and contact the pharmacy if you discover an error. |
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Health Care Fraud |