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Common types of healthcare fraud

On Behalf of | Feb 14, 2024 | HEALTH & HEALTH CARE LAW - Health & Health Care Law |

Healthcare fraud is a serious offense that involves deceitful practices aimed at unlawfully obtaining benefits or payments from health insurance programs. It can occur in various forms and can involve individuals, healthcare providers or organizations.

Understanding the common types of healthcare fraud is crucial for effectively preventing and combating these fraudulent activities.

Billing fraud

Billing fraud is one of the most prevalent types of healthcare fraud. It involves intentionally billing for services that were not provided or billing for more expensive services than those actually rendered. Common examples include:

  • Upcoding: Charging for a more expensive service than what was provided.
  • Phantom billing: Billing for services or procedures that were never performed.
  • Unbundling: Billing separately for services that should be billed together as a package deal.
  • Prescription fraud: Occurs when providers unlawfully obtain prescription drugs or submit false claims for reimbursement.

By contrast, kickbacks involve offering or receiving incentives in exchange for patient referrals or purchasing medical services or supplies. A self-referral is when a doctor refers their patient to a service provider or facility they have a financial interest in. Both practices are illegal and can lead to compromised patient care and inflated costs.

Medicare fraud

Medicare fraud specifically targets the Medicare program, which provides health insurance for individuals aged 65 and older. Common schemes include:

  • Phantom Billing for Medicare services.
  • Fraudulent Medicare claims for unnecessary medical equipment or services.
  • Medicare Identity Theft: Using stolen Medicare information to submit fraudulent claims.

Healthcare fraud undermines the integrity of the healthcare system, wastes resources and jeopardizes patient safety. Recognizing the common types of healthcare fraud is essential for implementing effective prevention and detection strategies to safeguard patients and the healthcare system alike.