The biggest source of insurance fraud is medical providers, not the people who receive benefits. An individual can only successfully obtain a limited amount of benefits for themselves when committing fraud, while providers could theoretically bill for hundreds or thousands of procedures they didn't perform or performed unnecessarily just for compensation.
Working in health care means taking certain risks. In addition to the risks that come from interacting with patients and potentially hazardous materials like bodily fluids, people working in the medical profession also run the risk of involvement in criminal activities, sometimes without realizing it.
Involvement in a medical insurance fraud scheme could have dire implications for your future. Whether you work as a physician's assistant or a billing specialist, familiarizing yourself with the common forms of medical insurance fraud can help you avoid unwittingly taking part in any of them.
Doctors may bill for procedures they never perform
A common form of medical fraud involves a doctor billing for their time and services related to a procedure that never took place. Patients often don't carefully monitor their insurance billing statement when they have full coverage. That can mean that doctors can submit numerous fraudulent charges without anyone realizing it.
Doctors may submit additions to charts or new billing requests without having seen the patient again. If you suspect fraud, comparing procedure dates with billing records is one way to confirm your suspicions.
Intentionally unbundling procedures or billing for something more expensive
As a part of the negotiation process for setting the reimbursement rate on various medical procedures, medical providers and insurance companies often bundle certain common procedures together. They do this to offer the best possible pricing. Billing specialist or doctors may intentionally unbundle services to bill for more money than they should.
Other times, they may submit a bill twice for the same thing or bill for a more expensive version of what was done or administered. A doctor could claim they spent twice as long with a patient as they did, allowing them to make more money without doing the work.
Some doctors perform unnecessary procedures
People who commit medical fraud don't want to get caught, as they know they could face serious penalties. To avoid discrepancies between billing and work history, some doctors will go to the extreme measure of intentionally performing unnecessary surgeries to bill for those procedures. Doing so can endanger patients and unnecessarily drain public Insurance programs meant to protect the vulnerable.
If you have been accused of participating in any kind of medical billing fraud, speaking with an experienced attorney as soon as possible is in your best interest. The same is true if you suspect fraud at your workplace.