Health care fraud associated with government benefit plans like Medicare, Medicaid and TriCare is unfortunately not uncommon. Each year, fraudulent or improper claims cost the government millions of dollars. However, given the number of claims filed, spotting fraudulent practices can be challenging.
Whether you are a patient or employee, you might notice something seems wrong. For the most part, medical providers are transparent in their billing practices, but there are times when health care fraud may occur. Both patients and employees can benefit from understanding some common types of health care fraud so that they can potentially take action should they encounter such fraudulent behavior.
Breaking down common types of fraud
Five common types of health care fraud that occur include:
- Upcoding or billing fraud. Upcoding can include using billing codes to charge patients for more expensive or complex procedures than were needed. Other types of billing fraud can include adding on extra charges or claims to the services actually received.
- Falsifying medical records. Providers might falsify a patient’s medical record in order to support an unnecessary claim for payment.
- Accepting kickbacks. Kickbacks are compensation in exchange for using a certain drug or product. These can be made through cash, Medicare, Medicaid, patient referrals, gifts and more.
- Unbundling. This can occur when a provider bills for separate services that are normally billed together at a discounted rate. “Unbundling” these services allows providers to collect more compensation over time.
- Committing Medicare Part D fraud. As Medicare Part D covers prescription drugs, pharmacies may bill patients for brand name drugs rather than generic versions, fill nonexistent prescriptions, fill prescriptions that are not Medicare-eligible and more.
Reporting health care fraud
Both patients and employees are typically in the best positions to report fraud stemming from government benefit plans. Making the decision to report fraud can be a difficult one, especially if you believe your career could be threatened. These are complicated matters. After carefully reviewing the information you have obtained, seeking the help of an attorney experienced in assisting whistleblowers, as well as protecting whistleblowers from retaliation, can be beneficial.