1. Billing for Services Not Rendered (Upcoding/Downcoding)
This is one of the most common forms of medical fraud, and it’s also known as “unbundling.” It refers to a provider submitting claims for services that were not rendered or performed in full. These fraudulent bills may be billed at the highest levels of reimbursement possible under Medicare and Medicaid. In many cases, the same service is billed separately, which causes overbilling or duplicate billing.
Whether intentional or not, medical fraud defense lawyers can help you prepare your defense.
How to Prevent It
There are a number of ways to prevent billing for services not rendered, including using pre-certification programs and prior authorization requirements. Healthcare providers should also be aware of the various billing codes that correspond to specific procedures and services.
2. False Claims in General
Similarly to the above, false claims are another common form of medical fraud. This type of fraud occurs when a healthcare provider or company submits a false claim to Medicare, Medicaid, or another insurance program. This may involve billing for services that were not rendered, providing inaccurate information on invoices, or submitting duplicate bills.
3. Illegal Kickbacks
Kickbacks are another form of fraud that occurs when a patient or provider is paid for referring someone else to their practice. It may also happen when providers accept gifts from drug companies in exchange for prescribing certain medications to patients. This type of fraud has become increasingly common as more doctors receive kickback payments from pharmaceutical companies, which can be as high as $25,000 per patient.
4. Prescription Fraud
This type of fraud is often committed by a patient. Prescription fraud is the crime of obtaining prescription drugs through fraudulent means. This may involve forging prescriptions, stealing medications from pharmacies or hospitals, or buying drugs illegally on the street. Prescription drug fraud is a serious problem in the United States, and it costs taxpayers billions of dollars each year.
5. Waiver of Co-Payment, Deductible, or Co-Insurance
This type of fraud is committed when a provider waives the co-payment for services that are covered under Medicare or Medicaid. The provider might charge the patient an hourly rate instead of charging a flat fee per visit; this allows them to collect more money.
6. Self-Referral/Stark Law Violations
Similar to kickbacks, the self-referral law prohibits physicians from referring patients to receive certain designated health services at facilities where they have an ownership interest. This type of fraud is known as a “Stark” violation because the physician who commits it can be charged under the Anti-Kickback Statute.
7. False Diagnosis
Similarly to billing for services that were not performed, false diagnosis is the act of performing and billing for unnecessary procedures on the basis of a diagnosis that is incorrect.
8. False Certification
This type of fraud occurs when a health care provider knowingly provides false information in order to obtain payment from Medicare or Medicaid. For example, a physician may certify that an item is medically necessary for his patient’s treatment although he knows that it’s not covered by the program; this would constitute fraudulent billing practices under the False Claims Act.
How to Prevent Medical Fraud, to Begin With
There are a number of ways to prevent medical fraud from occurring, including using pre-certification programs and prior authorization requirements. Healthcare providers should also be aware of the various billing codes that correspond to specific procedures and services.
In addition, providers should be familiar with the False Claims Act and other anti-fraud statutes so they can avoid any potential violations.
A Must-Know: The Federal False Claims Act and Medical Fraud
The federal False Claims Act is another tool used to fight medical fraud in the United States. This law allows whistleblowers to file a lawsuit on behalf of the government if they believe that someone has committed fraud against it, such as Medicare or Medicaid. Under this statute, the government can recover triple the amount of damages that were caused by the fraud.If you are facing charges related to medical fraud, it is important to seek legal counsel from an experienced attorney who can help you build a strong defense. Attorneys that specialize in this area have extensive experience handling cases involving all types of medical fraud. A good lawyer understands how devastating these charges can be for both the victim and perpetrator and will work diligently to get the best possible outcome for your case.