If you are planning to buy health insurance for your health then it is very important for you to know how many types Of Health Insurance Frauds there are.
According to the FBI Healthcare fraud and abuse refer to deceptive practices in the healthcare industry that lead to unprofitable profits. These plans cost the nation billions of dollars each year and result in increased health insurance premiums and out-of-pocket expenses for consumers.
Health care fraud is the intentional fraud or misrepresentation of services that result in unauthorized returns.
Misuse of health care refers to practices that are incompatible with accepted medical, occupational, or financial practices.
You find here 9 Types Of Health Insurance Frauds real full article.
Table of Contents
What is health insurance frauds
Healthcare fraud is not a crime without victims. It affects everyone individuals and businesses alike and causes billions of dollars in damage each year.
It can increase health insurance premiums, expose you to unnecessary medical procedures and raise taxes.
In this type of fraud, the health insurance company provides false or misleading information in an attempt to pay unauthorized benefits to the policyholder, another party, or organization providing the services.
The offense may be committed by the insured or by a health care provider.
Health insurance investigation
The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs.
The FBI investigates these crimes in partnership with:
- Federal, state, and local agencies
- Healthcare Fraud Prevention Partnership
- Insurance groups such as the National Health Care Anti-Fraud Association, the National Insurance Crime Bureau, and insurance investigation units
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9 Types Of Health Insurance Frauds
- Incorrect reporting of diagnoses or procedures (including unbundling).
- Billing for non-covered service as a covered service.
- Misrepresentation of service dates.
- Incorrectly represents service locations.Corruption (kickbacks and bribes).
- Misrepresentation of the service providers.
- Deductible and/or co-payment waiver.
- Billing for services has not been rendered.
- Overuse of services.
- False or unnecessary issuance of prescription drugs.
Details of 9 Types Of Health Insurance Frauds.
#1 Incorrect reporting of diagnoses or procedures (including unbundling).
This provider plan is similar to the one frequently used in the auto repair industry. As you probably know, it costs more to tune up a car and replace an air filter. But if an auto-repair business charges you for a tune-up but only replaces the air filter, it is making money illegally. Making a list of misdiagnoses or procedures is essentially the same thing.
Unethical providers may bill for additional services if they report a false serious diagnosis or action taken. For example, if an elderly patient is allegedly lying inside a nursing home, the crooked provider may deliberately misdiagnose him with head trauma that requires the use of computed tomography (CT) scans and/or blood tests (unnecessarily). this Types Of Health Insurance fraud is serious.
#2 Billing for non-covered service as a covered service.
This Types Of Health Insurance Frauds is During one of the fraudulent examinations I conducted, the allergy doctor was treating, which was considered experimental and therefore not approved by government health care plans or other insurance companies.
With a few strokes of pen or tape on the keyboard, the allergist doctor submitted claim forms and was still paid to use the experimental treatment. She accomplished this by calling (and coding) something else covered by insurance plans and policies.
Like most other criminals, this doctor justified his wrongdoing. She believes that she is providing useful services to her allergy sufferers and that it is not her fault that the government and insurance companies have not yet approved the experimental treatment.
#3 Misrepresentation of service dates.
Providers can earn more money by reporting that they have visited or treated the same patient on two different days instead of one day. Each “office visit” is generally considered a separate billing service. Often the fraudsters actually provide the services listed on the claim form, but the dates are incorrect because it is more profitable for the providers.
So check to make sure the patient’s medical file documentation matches the dates of service listed on the claim form.
#4 Incorrectly represents service locations.
Let’s go back to that allergy clinic. When I interviewed patients at their homes, many people who had previously told me that they only took injections twice a week told me that they only went to an allergy clinic once a month.
Patients said that the staff at the allergy clinic would give each of them a set of syringes filled with antigens and ask them to give them an injection in their home!
Because I’m a little shy about needles, and the thought of injecting myself shocks me, I wondered if insurance companies would deliberately allow self-injection away from an allergy clinic.
An insurance company expert told me that they (and most other companies) do not accept self-injection as a reimbursable expense.
The specialist said that medical providers should monitor patients for a few minutes after the injection to ensure that patients do not have adverse reactions.
#5 Misrepresentation of the service providers.
It’s a scary idea that one can pretend to be a doctor and pay the bill for treatment, but it happens.
I have conducted numerous checks in which medical doctors have signed insurance claim forms showing that they provided all the care but in reality, less educated mental health professionals actually carried out the treatment.
In these cases, the affected insurance companies would still have paid for the care provided by the less-educated physicians (as long as they were licensed), but they would have paid less.
For example, I learned that licensed clinical social workers are often paid less than physicians.
#6 Deductible and/or co-payment waiver.
Apparently, patients rarely complain when the cost is out of their pocket or non-existent.
Most government health care plans and insurance companies do not allow medical providers or facilities to waive patients’ deductions or co-payments. The logic may be that if patients have to pay something to see a doctor, they will only care if they really need it. Maybe it’s also a way to offset some of the costs.
Regardless, some providers waive patient deductions or co-payments and then submit other false claims to insurance companies to make up the dollar difference.
The truly unethical providers will also add a bunch of other false services to the claim form to increase their illicit profits that patients are not likely to complain about because their co-payments and deductions were waived.
#7 Billing for services has not been rendered.
In almost every health care fraud exam, I have conducted, I have found evidence that a medical provider or its facility has submitted claim forms for services and care to government health care plans and/or insurance companies – which have never been provided – and the corresponding patient The files did not have any supporting documents.
It makes sense that if a fraudster does any of the other schemes listed above, which takes a little brainstorming and effort, they may even throw in some extra dates and codes on the claim forms to try to make some really easy money.
During the initial stages of health care fraud examination or investigation, I identify the recorded dates of service listed in the claim form and then look for any documentary evidence that patients were at the facility on those dates.
#8 Overuse of services.
This usually includes billing for services that are not really required – such as completion and billing for unnecessary car tune-ups. Unethical providers use this scheme on hypochondriac patients.
Tests and examinations may continue indefinitely or at least as long as the patient has coverage or is able to pay. Alcohol and drug rehabilitation facilities are suitable for overuse.
#9 False or unnecessary issuance of prescription drugs.
Prescription drug abuse is sometimes defined as taking a prescription drug (prescribed or not) for reasons beyond the physicians’ intent.
A 214-page 2005 report prepared by the National Center on Addiction and Substance Abuse (CASA) “Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the US.” After reading this I first became aware of the seriousness and growth of this problem. At Columbia University. According to the report, the number of U.S. citizens abusing controlled prescription drugs increased from about 7.8 million in 1992 to 2003 to 15.1 million.
After 9 Types Of Health Insurance Frauds, we see Health insurance frauds punishment
Health insurance frauds punishment
Criminal penalties for knowingly submitting false Medicare claims, giving kickbacks, or accepting kickbacks can be significant.
If a person is found guilty of making a fraudulent claim as described in the False Claims Act, he or she could face up to five years in prison and a fine of up to $ 250,000.
Those found guilty of violating anti-kickback laws could face up to 25,000 in fines and up to five years in prison.
Conclusion on Types Of Health Insurance Frauds
The health care profession is full of honest, ethical, dedicated, and committed individuals. However, like all industries, there are those who betray their peers and society.
The description of the plan given in this article will start you to learn how to fight this crisis, help the victims and reduce the rising cost of health care.