Health care fraud is committed when a dishonest provider or consumer intentionally submits false or misleading information for use in determining the amount of a health insurance claim. Health care fraud increases the cost of health care benefits for everyone.
Estimates by government and law enforcement agencies place the financial loss due to health care fraud as high as 10% of our nation’s annual health care expenditure – or a staggering $226 billion – each year. Health care fraud translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage.
Provider health care fraud:
- Billing for services not actually performed.
- Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.
- Misrepresenting procedures performed to obtain payment for services that are not covered.
- Up coding – billing for a more costly service than the one actually performed.
- Unbundling – billing each stage of a procedure as if it were a separate procedure.
- Accepting kickbacks for patient referrals.
- Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.
- Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
Consumer health care fraud:
- Filing claims for services or medications not received.
- Forging or altering bills or receipts.
- Using someone else’s coverage or insurance card.
Medicare fraud:
Medicare fraud can take the form of any of the health insurance frauds described above. Senior citizens are frequent targets of Medicare schemes.
