How Do Fraudulent Insurance Claims Affect Medicare?

September 7th, 2018 by Mike Bothwell

Fraudulent insurance claims rob needy people of adequate healthcare.

Fraudulent Insurance ClaimsFraudulent insurance claims come in all varieties, and ultimately, it is the people who need the most who suffer more than anyone else. Substandard providers make money off the poor while delivering shoddy services. When a problem is widespread enough, policies change to limit services to keep unscrupulous medical providers from taking advantage of them. You can help preserve services and employment opportunities for those who are above-board by reporting fraudulent billing practices.

Common Types of Fraudulent Claims

It’s not always easy for a patient to identify fraudulent Medicaid billing. Providers can change someone’s address, for instance, so bills go to the wrong address. They can also be confusing for laymen to understand. However, it might help to know the main ways health providers defraud the Medicaid system.

The most common types of insurance fraud include:

  • Billing for the wrong services
  • Billing for services never provided
  • Changing the date of services rendered
  • Providing and billing for unnecessary services
  • Naming the wrong patient

Let’s go through each type of fraud and explain how it might show up on your medical bill. If you notice problems, be sure to get in touch with a lawyer who has experience in whistleblower laws. If the court finds the provider guilty, you might be able to collect a partial settlement.

Billing for the Wrong Services or Those Never Provided

Different types of medical care receive reimbursement at different rates. For instance, if you go in for a typical dental cleaning, your bill should say “Prophylaxis” instead of “Periodontal Scaling and Root-Planing.” The latter is a more labor-intensive service, so it justifies a higher payment from insurance plans.

Insurance companies know some medial practices bill incorrectly, which is why they put measures in place to justify upgraded services. For example, they might require additional x-rays or an in-depth assessment of periodontal disease before signing off on a scaling and root-planing service fee. If you’re seeing several additional services on your bill you don’t remember experiencing during your visit, there’s a good chance your bill is inaccurate.  

Some patients might shrug this off in the moment, but your insurance might only cover one of these services a year. So they won’t cover the charge if the care becomes necessary later in the year.

Changing the Date of Appointments on Medical Bills

Changing dates on medical billing is one of the latest methods dishonest doctors are using to boost their profits. They split up billing for a single visit between several different days. If you went to the doctor over a persistent cold and received an allergy test, you might get two separate bills with two different dates on them. By splitting up the services, your doctor’s office can charge the insurance provider double for office visits and associated fees.

Providing Unnecessary Services to Justify Additional Charges

Providing unnecessary services is one of the most dangerous types of insurance fraud in existence today. Instead of lying about the level of care they provided, some practitioners protect themselves against fraudulent billing claims by delivering unnecessary treatments. This seemingly ensures an airtight paper trail regardless of the type of investigation performed. Unfortunately, providers who take part in this scheme build up a tolerance to their actions over time until office staff reports the activities.

Any practice dependent on Medicaid needs to be under scrutiny to prevent these types of patient abuses from occurring. Dentists will cap every tooth in a child’s mouth or push a patient to undergo a preventive knee replacement surgery in order to bill for high-dollar services.

The problem doesn’t stop at the unnecessary risks patients undergo, or the lasting impact invasive procedures have on their quality of life. When this type of fraud is persistent, the insurance provider raises the standards of proof necessary for essential procedures. People who genuinely need them have a hard time getting them covered by insurance — if they can get them at all.  

Second opinions exist for a reason. Be sure to get one before your doctor or other health care provider convinces you to undergo an expensive procedure.

Billing the Wrong Patient

It may seem like it’s in the spirit of Robin Hood to use one patient’s access to affordable health care to provide care for someone going without the necessary care. The problem is the doctors who make these kinds of deals are often taking some sort of payment and funneling it straight to their bank accounts. Additionally, problems arise when the person whose insurance is utilized needs services of their own. Due to limits and restrictions on covered care, the real insured patient might have to pay out-of-pocket.

The coding involved in medical billing is complicated and mistakes will happen from time to time. However, when doctors or staff deal with records incorrectly on purpose, they put people at risk. Help us fight back.

Contact the skilled fraudulent insurance claims attorneys at Bothwell Law Group online or by calling 770.643.1606 today.

Have Questions? Contact Us Today.


All conversations are confidential for your protection.

Contact Us