HEALTH CARE FRAUD Flashcards
Definition
Health care fraud involves a deception or misrepresentation that an individual or entity
makes, knowing that the misrepresentation could result in some unauthorised benefit to the
individual or to the entity or some other party. The most common fraud involves a false
statement or a misrepresentation or deliberate omission that is critical to the determination
of benefits.
Provider Fraud
Provider fraud is perpetrated by a physician, clinic, medical supplies vendor, or other provider
against patients to increase income
Provider Services Charged but not Rendered
A provider might submit charges for services not performed. This type of fraud is difficult
to uncover because it involves an omission of activity.
Provider Fraud Overutilisation
Overutilisation occurs when a physician prescribes unnecessary or excessive patient services
Provider Fraud Unnecessary Medical Testing
A service provider advises an insured that additional medical testing is needed to diagnose
the problem. In fact, the testing is not required and the fee for the unnecessary work often is
split with physicians.
Provider Fraud Fictitious Providers – Bogus Doctors
In this scheme an individual who is not a doctor opens a medical practice. The individual
obtains or creates a doctor’s ID number to appear legitimate. Thereafter, the fake doctor
bills the insurance company for the medical services.
Provider Fraud Photocopied Claim Forms with Benefit Assignment Repeatedly Submitted by a
Provider with New Date of Service
In this scheme a provider alters a genuine claim form signed by the patient. This method is
usually used by a provider with a small business or by an accounting secretary who submits
fictitious bills for his own benefit.
Provider Fraud Double Billing
Double billing occurs when the insured and/or the provider seek to be paid twice for the same service. The fraud might be perpetrated by the insured, with the complicity of the provider, or it might be done by the provider alone. The bill might be submitted to two (or more) different insurers, or it might be submitted twice to the same insurer with
documentation intended to show that two separate expenses have been incurred.
Provider Fraud Fictitious Diagnostic Codes
A false billing takes place if the physician or other primary provider knowingly enters an incorrect diagnostic code.
Provider Fraud Coding Fragmentation
Coding fragmentation involves the separation of one medical procedure into separate components to increase charges.
Provider Fraud Mutually Exclusive Procedures
A variation of unbundling, this scam involves billing for procedures that are either impossible to perform together or, by accepted standards, should not be performed together.
Provider Fraud Upcoding
Upcoding involves billing a higher level of service than was rendered.
Insured Fraud Fictitious Claims
As with false claims submitted by providers, the insured quite often will submit bogus claims
Insured Fraud Multiple Claims
The insured commits a fraud when he makes a claim for a covered loss without revealing
that he has already been paid for that loss. Such fraud may involve both fraudulent concealment of the prior claim(s) and payment(s) and misrepresentation that the loss has
been uncompensated.
Insured Fraud Alteration
A dishonest claimant can inflate a prescription or medical bill by placing an additional
number in front of the amount charged. The claimant can also alter the date of service so
that it becomes a recoverable expense rather than one incurred prior to eligibility. The individual submitting a claim may change the name on the bill from an uninsured family member to one included in the insurance plan.
