![]() Healthcare providers' excuses for missing documentation are sometimes almost humorous. However, a pattern of billing for services and care with no supporting documentation is unacceptable and unlikely to be coincidental. So, I realize that records can be misplaced, and, occasionally, somebody might forget to write something down. Our ability to empathize with others (including suspects) helps us treat them fairly and allows us to better understand their situations. Of course, you try to be fair and objective. If there's nothing there, I check the appointment calendars. If I find no documentation, I check the facility's sign-in logs. If a staff member had seen the patient, obviously somebody should have written something down - even if it was just documenting the patient's height and/or weight. ![]() It makes sense that if a fraudster would commit any of the other schemes listed above, which takes a bit of brainpower and effort, they might as well throw in some extra dates and codes on the claim forms to try to make some real easy money.ĭuring the early stages of a health care fraud examination or investigation, I identify the reported dates of service listed on the claim forms and then look for any documentary evidence that the patients were at the facility on those dates. In almost every health care fraud examination I've conducted, I've found evidence that the medical provider or its facility submitted claim forms to government health care plans and/or insurance companies for services and care - that were never provided - and the corresponding patient files had no supporting documentation. False or unnecessary issuance of prescription drugs.Incorrect reporting of diagnoses or procedures (includes unbundling).Waiving of deductibles and/or co-payments.Billing for a non-covered service as a covered service.(Also see the ACFE's 2013 Fraud Examiners Manual's section on health care fraud - beginning with 1.1101 - to learn more about these and other types of fraud schemes.) Ten common health care provider fraud schemes This list definitely isn't inclusive, but it will get you started on understanding how providers can be tempted to defraud a lumbering system. In this article, I describe 10 of the common health provider fraud schemes I've found, and I include some cases I've investigated. Although that's true of most health care providers and institutions, others do "go south." Most associate those individuals and entities with only doing good and helping others. Over the years, I've found investigating fraud committed by health care providers, facilities and institutions to be extremely fascinating, challenging and rewarding. Over the period of 2015-2021, health spending is projected to grow at an average rate of 6.2 percent annually. Affordable Care Act (ACA) - an estimated 22 million people will be insured. health spending to rise to 7.4 percent in 2014 as a result of the major coverage expansions from the U.S. reached $2.6 trillion in 2010 - 17.9 percent of GDP. According to the Centers for Medicare & Medicaid Services (CMS), national health expenditures in the U.S. The difference between the health care realm and many other industries is its huge, alluring, easy pile of cash. (Organized crime rings and computer hackers also play roles in committing health care fraud.) Health care crooks inside and outside the industry include patients, payers, employers, vendors and suppliers, and providers, including pharmacists. It's just one of a long list of crimes committed by a handful of crooked medical providers.Įssentially, fraud in health care is just like in any other industry: Fraudsters with the means and opportunity take full advantage to unjustly profit. I discovered this fraud during my investigation of the facility. Granted, it's a great movie, but each time the patients sat in front of the tube watching it, the facility submitted insurance claims for providing "group therapy." Patients with Alzheimer's disease were sitting unsupervised inside a small room of a medical psychological care facility watching the movie "Forrest Gump" for the umpteenth time. Learn some of the basic health care provider schemes and how to deter them from taking some easy money. ![]() However, a few want to illegally increase the size of their bank accounts. Most medical providers are honest and work hard to improve their patients' health.
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