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9 Main Methods of Medical Provider Fraud

There are many different types of healthcare fraud. At the end of the day, some people don’t have a moral compass and don’t have ethical standards. Some of these people end up in different areas of healthcare, like medical providers. These individuals bend the rules for their personal gain. Over time, healthcare fraudsters get more creative and their techniques become more extreme. LINKS: ____________________________________________ https://etactics.com/blog/healthcare-... ____________________________________________ The first method is something called double billing. Double billing happens when a provider submits the same claims for the same service more than once. From a fraud perspective, the provider tricks the insurance companies to pay the healthcare entity more than the allotted amount. It’s a method to artificially inflate the number of patients a doctor sees and the practice’s bottom line. Similarly, there’s another term called unbundling. Unbundling happens when a healthcare entity submits multiple bills for the same service. Although this sounds similar to double billing, there IS a difference. Unbundling involves billing for each step of a procedure as if they are separate procedures. This is also a method to artificially inflate a practice’s revenue and profit margins. Phantom billing is a form of medical provider fraud. This method involves billing for services that were never rendered. The healthcare provider uses genuine patient information, sometimes through employing identity theft, to fabricate claims. Phantom billing can also happen when legitimate claims have charges for procedures or services that never took place. A telltale sign of phantom billing is that there’s a lack of supporting documentation for the fake claims. For example, if there’s a lack of documentation such as height and/or weight, there’s a good chance the claims are fake. Billing for a non-covered service through false pretenses as a covered service is another form of medical provider fraud. This type occurs when a doctor tries to obtain insurance payments by disguising the treatment they provide as a different, medically necessary covered treatment. This type of fraud is often seen in the world of cosmetic surgery schemes. However, this phenomenon also occurs in other realms of medicine, especially when it comes to experimental treatments. Sometimes doctors will treat someone with an experimental medicine, but bill the insurance companies with a different code that’s accepted. Upcoding is a type of billing fraud where a healthcare entity falsely bills for a higher-priced treatment than was actually provided. This often requires the accompanying “inflation” of the patient’s diagnosis code. The doctor will falsely diagnose the patient in bills for a more serious condition consistent with the false procedure. For example, a doctor could intentionally misdiagnose an elderly patient who fell inside a nursing home with “head trauma” needing a CT scan and blood tests. The crooked provider didn’t necessarily draw blood or conduct the scan, but they falsely report it on paper. One of the telltale signs of this type of fraud is that an in-patient will mysteriously get better as soon as insurance coverage runs out. Similarly, some fraudsters perform medically unnecessary services. The sole purpose of this is to generate insurance payments to fraudulently increase the provider’s bottom line. Common examples of this fraud scheme include nerve conditions and genetic testing. Another similar fraud scheme is when a doctor falsifies a patient’s diagnosis and medical records. They do this to justify tests, surgeries, and other procedures that aren’t medically necessary. Unlike upcoding, doctors who engage in this type of fraud will actually conduct unnecessary procedures. ► Reach out to Etactics @ https://www.etactics.com​ ►Subscribe: https://rb.gy/pso1fq​ to learn more tips and tricks in healthcare, health IT, and cybersecurity. ►Find us on LinkedIn:   / etactics-inc   ►Find us on Facebook:   / ​   #MedicalFraud #FraudWasteandAbuse