In the U.S., an estimated $80 billion is lost each year to health care fraud and abuse. This fraud leads to higher health care costs for everyone. The majority of medical providers are honest, but there are some that commit fraud. The complexity of the billing system in the U.S. makes fraud easy to commit and hard to detect.
What is health care fraud and abuse?
Health care fraud occurs when a person or entity intentionally misrepresents facts or deceives another individual or entity in order to secure an unauthorized payment or benefit. Abuse occurs when a person or entity engages in actions that are inappropriate and that are outside of what is medically necessary. As health care costs have continued to increase, the focus on them has as well.
Many different health care providers have been investigated for fraud. On average, anti-fraud operations at a health plan save as much as $17 million per year, using sophisticated software programs and awareness campaigns.
Most common types of health care fraud and abuse
Here are 15 of the most common types of health care fraud and abuse that affect the health care system in the U.S.:
- Upcoding – Submitting claims that are more severe than the services that were actually provided
- Cloning- Automatically generating more detailed patient files by copying from the files of other patients who have similar symptoms in order to make it look like a more thorough service was provided
- Phantom billing- Billing for services that were not performed
- Inflated bills at the hospital- Grossly overcharging for equipment or procedures
- Unbundling services- Billing for several procedures separately instead of bundling them in order to get around the bundled rate
- Self-referrals- When providers refer themselves to perform services for financial gain
- Repeat billing- Billing twice for the same service or supplies
- Fraud about the length of stay- Charging for time that wasn’t spent in the facility
- Billing for the wrong type of room
- Billing for more time in the operating room than the time that was actually spent
- Coding mistakes- Entering the wrong codes so that substantial overcharges result
- Charging for canceled services
- Charging for services that caused the patient’s health to decline
- Charging for services that did not meet the standards of care
- Provision of unneeded tests or treatments
Contact Swartz Swidler
If you believe that you or your insurance company has been the victim of health care fraud, contact your insurance company immediately. You should also get help from the experienced lawyers at Swartz Swidler. Complete our contact form, and we will return your call as soon as possible.
