TYPES OF HEATH CARE FRAUD
False Certifications and Information
This type of fraud simply occurs when health care providers submit claims containing false statements.
Example: Health care provider employees/presidents forge doctor signatures on reports in order to make claims.
Fraudulent Cost Reports
Medicare uses cost reports to determine an amount in reimbursements it should give a health care provider. Providers who purposely inflate their costs incurred, misconstrue the nature of their costs, or give a false percentage of their services dedicated to Medicare patients are liable under the False Claims Act.
Example: Managers disguise personal expenses as Medicare billings and add them to cost reports.
Grant or Program Fraud
The federal government often grants funds for numerous types of research and other specialized projects in the arena of health care. Grant or program fraud occurs when the groups receiving the funds make false claims regarding their credentials, research, or projected research costs.
Example: A doctor applies for a grant under false qualifications, or the basis of the research operating under a grant does not meet the quality standards laid out by the grant.
Kickbacks
Kickbacks involve secret financial agreements between various health care providers. These providers will provide some material benefit in exchange for other providers prescribing or using their products or services. In cases where a kickback results in the government paying for medically unnecessary services or being overcharged, it can be considered a false claim.
Example: A company gives physicians income guarantees, office-rent subsidies, low-interest/no-interest loans, forgives re-payment of loans, and provides staff support in return for the physicians making referrals to their company.
Lack of Medical Necessity
This type of fraud occurs when health care providers bill Medicare and Medicaid for services or procedures that are not medically necessary.
Example: A doctor bills Medicare for X-rays and other tests regardless of whether or not the patient needed the procedures.
Services Not Rendered
The most common health care fraud is when health care providers bill Medicare or Medicaid for services that were never performed.
Example: A physical therapist bills for a session he never performed, a hospital bills for medical supplies it never ordered or received, or a doctor bills an extra hour for every
patient he sees.
Upcoding
To write up a bill for Medicare or Medicaid, doctors and hospitals use numerical codes to account for their services. Each code represents a different reimbursement amount. This system can then allow for some padding if a doctor or hospital is so inclined.
Example: Medicare will pay more for an X-ray is it is used to detect a tumor or disease than if it is used for a routine check-up. So doctors and hospitals will sometimes upcode their routine X-rays to be perceived as more important.
Unbundling or Fragmentation
Medicare and Medicaid offer discount incentives for groups of procedures that are often performed together. So to increase the reimbursement amounts, doctors and hospitals will unbundle the groups of procedures and bill for each part of the group.
-Example: A hospital bills 200 individual blood tests individually to Medicaid when the hospital is already receiving a reimbursement for the whole group.
If you have been witness to these or any other activities that could be considered illegal under the False Claims Act, contact Halunen & Associates.