Recently I learned that September is National Healthcare Fraud Prevention and Awareness Month. With this being the last Friday in the month, let’s take a look at Healthcare Fraud; what it is, common types, and how to protect yourself.
Healthcare fraud is committed when someone intentionally deceives the health care system to receive illegal benefits or payments. This type of fraud can be committed by both medical providers and patients. The FBI is the primary agency for investigating health care fraud for both federal and private insurance companies. They partner with Federal, state and local agencies as well as insurance groups to examine cases of suspected health care fraud in order to stop these criminals in their tracks. There are several ways that health care fraud is carried out and no matter the method, it causes tens of billions of dollars in losses each year. It can raise insurance premiums, expose patients to unnecessary tests or medical procedures, and increase taxes. Here are some common types of health care fraud:
Fraud committed by medical providers
- Double billing: Medical providers will some times bill both the insurance and the patient in an attempt to get paid twice for the same services rendered.
- Phantom billing: Billing for a service, visit, or supplies the patient never received.
- Unbundling: Providers break down a single comprehensive service into smaller components and bill for each part separately in order to increase the total cost of a procedure.
- Upcoding: Billing for a more expensive service than the patient actually received.
- Kickbacks: Providers offer or accept illegal payments in exchange for patient information, referrals, or business. Unfortunately, this is a common practice in health care fraud.
- False or unnecessary services: Providers may bill for procedures, medications, supplies, or tests that either never occurred or were unnecessary to the patient’s diagnosis.
Fraud committed by patients and other individuals
- Bogus marketing: This is the act of convincing people to provide their health insurance number and other personal information in order to bill for non-rendered services, steal patient identity, or enroll them in a fake benefit plan.
- Medical identity theft: Using another person’s name, insurance ID, or personal information to obtain healthcare services or prescription drugs.
- Identity swapping: Allowing another person to use your health insurance information or using someone else’s insurance to receive services.
- False information: Providing inaccurate details on insurance applications, medical history forms, or other documents to obtain coverage or services.
- Faked injuries or illnesses: Staging an accident, exaggerating symptoms, lying or pretending to be sick or hurt in order to receive services or prescription drugs.
- Impersonating a health care professional: Providing or billing for health services or equipment without a license.
Fraud involving prescriptions
Another way providers and patients engage in healthcare fraud is through prescriptions. Some doctors may write prescriptions for controlled substances without a legitimate medical purpose for family or staff. Patients have been known to steal prescription pads and forge signatures to get the medication they are after. Here are a few other examples of prescription fraud:
- Prescription drug switching: This occurs when a pharmacy substitutes a cheaper medication for a more expensive one while billing the patient or insurance for the higher-cost drug.
- Billing fraud: Medicare or other government programs sometimes get billed for meds that were never dispensed or picked up.
- Counterfeit drugs: The manufacture and sale of fake drugs that lack the active ingredient needed can occur which poses serious health risks to patients.
- Doctor Shopping: Some patients visit multiple doctors in search of controlled substances. Other patients visit ERs often in search of pain medication. These people are commonly referred to as “frequent fliers” in hospitals.
- Prescription Diversion: Patients obtain legal prescriptions and then sell them illegally to others for financial gain.
Healthcare fraud is not a victimless crime. You can help to protect yourself by safeguarding insurance cards and information, being aware of “free” services, and checking your explanation of benefits (EOB) regularly. If you have any concerns at all you should contact your insurance provider immediately. Always report any suspected healthcare fraud to the FBI’s Internet Crime Complaint Center at ic3.gov. If you are prescribed medication from a doctor, it is meant for you to take and not share with others. Do not allow anyone to use your insurance to purchase medication or see a doctor themselves. By keeping your personal information close you can help to prevent healthcare fraud from happening to you.
