Of all cases of medical insurance fraud that occur each year, Medicare fraud is the largest source. In 2014, fraudsters scammed Medicare for over $60 billion, and over 2,000 providers have been caught defrauding Medicare. Pursuing Medicare fraud can be difficult due to the prevalence of fraud as well as the sheer number of people involved in defrauding Medicare.
What Is Medical Insurance Fraud?
Medical insurance fraud occurs when a provider or consumer intentionally submits fraudulent information that is used to determine health care benefits payable. Because of the cost of health care and medical equipment, the idea of pocketing the payout of billing for services or equipment that were not rendered is a tempting one for providers and consumers alike. While Medicare is the organization that is most affected by fraud, it can affect any heath insurance company, and can be perpetuated by individual doctors as well as organized groups.
Medicare and related government-provided coverage is the most common target for insurance fraud for a few primary reasons:
- Over 54 million people are covered by Medicare, and the organization pays out over $600 billion each year.
- The organization is subjected to the loosest monitoring by those in charge.
- Billions of dollars are left largely unguarded and ripe for targeting by scam artists.
How Is Medical Insurance Fraud Perpetuated?
There are various ways providers and consumers can commit medical insurance fraud. Some of the most common seen by investigators include the following:
- Billing for medical equipment, medication, or services that were not actually rendered, received, or performed.
- Falsifying a patient’s diagnosis to justify procedures, equipment, surgery, or other procedures that were not medically necessary.
- Upcoding and Unbundling. Upcoding is billing for a service more costly than the one performed. Unbundling is the billing of each step of a procedure as separate procedures.
- Accepting kickbacks in exchange for patient referrals.
- Waiving co-pays or deductibles and over-billing the insurance company.
- Forging or alteration of medical bills or receipts.
- Using someone else’s health coverage or insurance card.
Combating Medical Insurance Fraud – a Lengthy Process
Medical insurance fraud is a crime that has serious ramifications for everyone. Every time fraud is committed, it raises the cost of health care for millions of other Americans. So it is important that medical insurance fraud is pursued and prosecuted in order to recoup the amounts that were defrauded.
The challenge in pursuing insurance fraud is finding individuals who are both willing to cooperate with investigators and who have sufficient evidence to back up their claims. Even when a whistleblower contacts authorities with information, it can be a long and arduous process to gather more evidence and bring a court case. But these cases must be pursued in order to help combat the rapidly-rising costs of health care in the United States.
If you have witnessed or participated in medical insurance fraud, you will need protections should you choose to come forward as a whistleblower. Contact the skilled whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.
If you’re wondering how to report healthcare fraud, you’re probably already in an uncomfortable position. Someone you work for (or with) is doing something illegal to defraud the government and the healthcare system it supports. You’ve found out, and now you think you need to do something about it.
The False Claim Act for healthcare is essentially a small component of a much larger set of regulations making it a crime to knowingly record or file a false claim, regarding any federal healthcare program. While Medicare and Medicaid are both considered federally funded programs, it also extends coverage to any plan or program providing health benefits (including through insurance) which receives any funding from the federal government or state-sponsored healthcare system.
In a recent fraud claims settlement by Bothwell Law Group, Georgia area hospice center Guardian Hospice has reached a $3 million settlement. Together with their affiliated organizations, Guardian Home Care Holdings and AccentCare, Guardian Hospice was accused by a whistleblower of submitting false claims to Medicare and Medicaid.
If you need to bring a medical claim against a doctor or hospital, you will need help. A medical malpractice attorney can make the difference in winning and losing your case.
