Real-World Healthcare Fraud Examples
1.9 هزار بار بازدید -
2 سال پیش
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We’ve talked about it before.
We’ve talked about it before. It can be difficult to collect on patient statements. Whether it’s due to claim delays, claim denials, or the patient just isn’t able to pay their balance… it still hurts your pocket the same.
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https://etactics.com/blog/healthcare-...
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Desperate times can call for desperate measures for those with a - let’s say, a loose moral compass. Healthcare fraud can happen when organizations are looking for a way to easily line their pockets, but at what cost?
The Department of Justice estimates that healthcare fraud generates close to 100 billion dollars a year. So, what is healthcare fraud anyway?
To put it simply, anyone who deceives the healthcare system for their benefit are guilty of healthcare fraud. Anyone can commit this kind of fraud and it affects everyone.
But the schemes that involve medical professionals committing the fraud can be some of the most difficult ones to detect. They can mimic legitimate transactions from insurers to providers and payments can clear more easily due to the generally high costs of pharmaceuticals and services.
In a survey by Accenture, around 24% of health employees say that they know someone who has sold their medical access to an unauthorized outsider.
This form of healthcare fraud is called “medical identity theft” and over 2 million Americans have become victims, according to the Medical Identity Theft Alliance.
In September of 2021, a Las Vegas resident received 144 months in federal prison and a $4,321,590.39 fine for conspiring to defraud the North Carolina Medical Program of over 10 million dollars. Both he and his wife face heavy consequences for billing the government with fake home and health services.
The couple was able to obtain medical information of recently deceased patients through their obituaries and then “back-bill” the government for services that were never given.
On top of medical identity theft, this couple billed for services that were never even rendered. This is another form of fraud called “phantom billing”.
There are a few other billing techniques that can constitute fraud, whether people do them intentionally or by accident. The term “double billing” is pretty straightforward, I think. Meaning a specific claim that gets submitted multiple times even though the service occurred once.
Billing for unnecessary services and upcoding is the next type of fraud. Not only do fraudsters enter services that were never done to generate a profit, they often will submit more expensive services that were not required.
For example, more than 12 million opioid pills are prescribed illegally a year. Armando Valdes received 60 months in federal prison for submitting approximately 38 million dollars in fraudulent claims.
Now, in some industries rewarding new sources is good. But when it comes to federal healthcare programs, things can become tricky. Kickbacks happen when a physician or medical provider offers payment or benefits to a patient so that they come to their office. This fraud can also include soliciting referrals from other providers.
In January of 2021, athenahealth Inc. paid over 18 million dollars to resolve its civil healthcare fraud case. Allegations arose that the organization paid kickbacks to generate sales of its electronic health records product.
These kickbacks involved inviting prospective and existing customers to fully paid recreational events, paying existing customers to identify and refer new customers, and setting deals to receive existing clients of competing vendors who were discontinuing their programs.
Healthcare fraud can happen in different ways. Avoiding this as both a patient and a provider will save you from potentially disastrous consequences. As a patient, make sure to take note of any billing items or services on your statement that have not been properly documented. As a healthcare entity make sure to hold your staff accountable for identifying signs of fraud.
► Reach out to Etactics @ https://www.etactics.com
►Subscribe: https://rb.gy/pso1fq to learn more tips and tricks in healthcare, health IT, and cybersecurity.
►Find us on LinkedIn: LinkedIn: etactics-inc
►Find us on Facebook: Facebook:
#healthcarefraud #fraud
LINKS:
____________________________________________
https://etactics.com/blog/healthcare-...
____________________________________________
Desperate times can call for desperate measures for those with a - let’s say, a loose moral compass. Healthcare fraud can happen when organizations are looking for a way to easily line their pockets, but at what cost?
The Department of Justice estimates that healthcare fraud generates close to 100 billion dollars a year. So, what is healthcare fraud anyway?
To put it simply, anyone who deceives the healthcare system for their benefit are guilty of healthcare fraud. Anyone can commit this kind of fraud and it affects everyone.
But the schemes that involve medical professionals committing the fraud can be some of the most difficult ones to detect. They can mimic legitimate transactions from insurers to providers and payments can clear more easily due to the generally high costs of pharmaceuticals and services.
In a survey by Accenture, around 24% of health employees say that they know someone who has sold their medical access to an unauthorized outsider.
This form of healthcare fraud is called “medical identity theft” and over 2 million Americans have become victims, according to the Medical Identity Theft Alliance.
In September of 2021, a Las Vegas resident received 144 months in federal prison and a $4,321,590.39 fine for conspiring to defraud the North Carolina Medical Program of over 10 million dollars. Both he and his wife face heavy consequences for billing the government with fake home and health services.
The couple was able to obtain medical information of recently deceased patients through their obituaries and then “back-bill” the government for services that were never given.
On top of medical identity theft, this couple billed for services that were never even rendered. This is another form of fraud called “phantom billing”.
There are a few other billing techniques that can constitute fraud, whether people do them intentionally or by accident. The term “double billing” is pretty straightforward, I think. Meaning a specific claim that gets submitted multiple times even though the service occurred once.
Billing for unnecessary services and upcoding is the next type of fraud. Not only do fraudsters enter services that were never done to generate a profit, they often will submit more expensive services that were not required.
For example, more than 12 million opioid pills are prescribed illegally a year. Armando Valdes received 60 months in federal prison for submitting approximately 38 million dollars in fraudulent claims.
Now, in some industries rewarding new sources is good. But when it comes to federal healthcare programs, things can become tricky. Kickbacks happen when a physician or medical provider offers payment or benefits to a patient so that they come to their office. This fraud can also include soliciting referrals from other providers.
In January of 2021, athenahealth Inc. paid over 18 million dollars to resolve its civil healthcare fraud case. Allegations arose that the organization paid kickbacks to generate sales of its electronic health records product.
These kickbacks involved inviting prospective and existing customers to fully paid recreational events, paying existing customers to identify and refer new customers, and setting deals to receive existing clients of competing vendors who were discontinuing their programs.
Healthcare fraud can happen in different ways. Avoiding this as both a patient and a provider will save you from potentially disastrous consequences. As a patient, make sure to take note of any billing items or services on your statement that have not been properly documented. As a healthcare entity make sure to hold your staff accountable for identifying signs of fraud.
► Reach out to Etactics @ https://www.etactics.com
►Subscribe: https://rb.gy/pso1fq to learn more tips and tricks in healthcare, health IT, and cybersecurity.
►Find us on LinkedIn: LinkedIn: etactics-inc
►Find us on Facebook: Facebook:
#healthcarefraud #fraud
2 سال پیش
در تاریخ 1401/07/06 منتشر شده
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