What’s the prescription for healthcare fraud?
The implementation of a strong compliance program with a 24/7/365 hotline!
The following are some of the symptoms of healthcare fraud that you need to be aware of.
Billing for services not rendered:
Unfortunately one of the easiest frauds to commit. Medical providers, or their facilities, will submit claim forms to the government healthcare plans or insurance companies for services and care that were never actually provided. Adding in dates or medical codes to claim forms for alleged services provided to patients, is unfortunately easily done.
Billing a non-covered service as a covered service:
Insurance is footing the bill for most patients, therefore, all the patient cares about is feeling better and not dipping too far into their wallets. So some medical providers will actually submit claim forms for experimental treatments, which are not approved or provided for by the government, and call these treatments something other than what they really are – usually something that is covered by insurance.
Billing different dates of service:
Medical providers might report that they visited with the same patient on two separate dates when in fact they did not. They do this in an effort to grow their billable services because each visit is considered a separate billed service
Misrepresenting provider of service:
In some cases, facilities will hire part time doctors, or unlicensed or lesser educated professionals to provide services to patients. These types of billed services actually reimburse less than the physicians. So the physicians will sign off on the claims for services provided for the purpose of receiving full reimbursement. What are these licenced physicians doing while lesser educated professionals are doing their work?
Billing for extra services:
Imagine what could be done with the elderly or those who are in poor health? Unethical healthcare providers could potentially have a field day with this. Imagine if an elderly patient falls in their Care Facility and the doctor diagnoses that patient with head trauma that doesn’t exist? Skies the limit for requesting unnecessary procedures like CT Scans or blood tests. Claiming these false services will bring in more reimbursement. There’s the ever popular scenario of an extended hospital say until the patient’s insurance runs out and the doctor claims the patient miraculously got better.
False issuance of prescription drugs:
One of the most popular overused drugs is painkillers. Street value of painkiller drugs is almost 10 times the legal prescription value. So it’s not too hard to imagine that in some pharmacies, a pharmacist will steal large quantities of painkillers, then electronically submit false claims to insurance using insurance policy numbers from friends and family, in a staggered fashion, in smaller quantities. These painkillers would then be sold on the street for a profit.
Whether it’s for regulatory compliance, financial transparency, corporate governance, employee, client, investor or patient relations, becoming WhistleBlower Secured™ will enhance your corporate integrity and empower your employees to contribute to an ethical workplace.
Source: Fraud Magazine – 10 popular health care provider fraud schemes