Cases involving doctors, hospital staff, patients and administrators defrauding the federal government out of large amounts of money through healthcare scams are, unfortunately, almost a monthly occurrence. Medicare fraud results in higher healthcare costs for everyone, and it is estimated that the government loses billions of dollars every year as the result of fraud. Multi-million dollar, and in sometimes over $1 billion, cases are publicized by government enforcement agencies – such as The U.S. Department of Health and Human Services’ Health Care Fraud Prevention and Enforcement Action Team (HEAT) and their targeted strike force teams – to try and inform the public about these schemes and serve as a warning to others who may try to perform similar unscrupulous acts.
Generally speaking, there are three main types of Medicare fraud – all of which involve either an individual or collective of co-conspirators falsifying official government documents with their own best interests in mind, usually at the expense of patients, the government or other healthcare professionals. The three main types of Medicare fraud are:
Phantom billing occurs when a hospital, treatment center or other kind of healthcare facility bills Medicare for services, drugs, treatments or any billable item that the patient did not knowingly authorize or did not receive. The fraudster may bill Medicare for a test that the patient did not require, and did not even undergo. In this type of fraud, the patient is not aware that the unauthorized billing is taking place.
In this form of fraud, the patient or patients are actually in on the scam. They will provide their Medicare information and then knowingly falsify claims that the healthcare provider makes about their treatment, usually for financial or medical-related kickbacks.
Upcoding and unbundling schemes
“Upcoding” schemes involve the healthcare provider pretending that a patient needs more expensive treatments and services than actually necessary by falsifying the Medicare billing codes. “Unbundling” refers to when a healthcare facility splits a series of tests or procedures into individually-billed items, which results in higher Medicare costs than if the tests or procedures were billed as a “bundle.”
The government does not play around with Medicare fraud
The United States Department of Health and Human Services, the Attorney General’s Office, the Office of the Inspector General and the United States Department of Justice combined resources in 2007 to create task forces specifically designed to go after all types of Medicare fraud in the country. They are based out of Florida, California, Michigan, Texas, New York, Louisiana and Illinois. These task forces, in accordance with their parent government agencies, relentlessly pursue fraud and have garnered some impressive results. According to their data, the task forces have found over 1,500 criminal actions, leading to 2,185 indictments and a grand total of nearly $2 billion in recovered money. Continue reading