White-collar crimes are constantly increasing with every passing day and the rapid technological developments are just fuelling this crime and making it grow at an exponential rate. Healthcare fraud is also a type of white-collar crime that involves filing of incorrect and fake healthcare forms and claims in order to make illegitimate profits. As these types of frauds take place in different ways, there are numerous frequently asked questions on medicare fraud and it can get tricky while keeping a track of these.
Right from patient registration forms and medical insurance forms to treatment recommended and administered, it is extremely important to be aware of everything that happens around a healthcare organization. Sometimes, it is really difficult to identify the fraudulent deeds happening around you. However, once you raise the voice against it, the impact it can have on you, should also be considered. In this article we have covered some of the most frequently asked questions on healthcare fraud and have answered them.
What Exactly is a Healthcare Fraud?
Medical fraud is a crime which involves intentional deception made by individuals or organizations to make illicit profits. There are various healthcare programs initiated by the government such as Medicare, Medicaid, TRICARE, etc., which cost the government billions of dollars every year. Healthcare frauds not only con honest taxpayers, but also risk the life of patients by recommending and administering unnecessary medical treatments and procedures.
How is Healthcare Fraud Different from Healthcare Abuse?
Every year fraudulent claims and healthcare programs cost the government billions of dollars. This can have an adverse effect on the country's economy and hence should be regularly kept in check. Often, people get confused about the difference between healthcare fraud and healthcare abuse. Here is the difference -
Healthcare fraud is an intentional misinterpretation or deception of services, which are known to an individual or organization to be false and involves unauthorized issuing of reimbursements to a medical organization
Healthcare abuses are the incidents or practices, which sway from the actual medical procedures and are different from the sound medical practice
What are the Common Instances of Medical Fraud?
Healthcare fraud cases are mostly complex, therefore, it is important to understand all the different types of frauds that occur in this industry. In general, healthcare fraud usually might involve any of the following -
Billing a more expensive service or procedure, than that was actually provided to the patient, which is also known as up-coding
Performing unnecessary procedures or providing unwanted services, solely for claiming insurance
Claiming that the patient's diagnosis is false to justify all the tests, procedures or surgeries conducted, which were not medically necessary
Accepting and giving kickbacks for any kind of patient referrals
Billing for services or procedures that were never provided by using genuine identity of the patient, which is obtained through identity theft
Waiving off any kind of patient deductibles or co-payments and charging the insurance providers more than the actual bill or invoice
How to Detect Healthcare Frauds?
The process of medical fraud detection involves detective investigation and account auditing. Careful investigations reveal suspicious policy holders and fraudulent insurance programs. As auditing all the claims is not feasible, a more practical approach of short listing claims having suspicious activities and then auditing the same is often followed. There are also many analytical processes, which are often used to generate audit short lists. Besides, fraudulent claims often leave patterns over time, which can be easily detected using predictive models.
How Can a Healthcare Fraud be Prevented?
Numerous cases of medical fraud and abuse can be avoided by ensuring that all the patient information submitted is correct and the services or procedures carried out are merely in the interest of the patient. Before evaluating the patient health and during information submission, the following points must be kept in mind -
Is the actual patient listed and whether the eligibility is verified
Is the identity of the patient verified using photo identification
Is the medical procedure recommended really necessary
Are there accurate CPT and diagnostic codes
Is the length of the session accurate and the session dates are correct
Whether the services billed were actually performed
Avail Quick and Efficient Healthcare Services at Flatworld Solutions
Flatworld Solutions has been providing top quality healthcare services to global clients for over a decade now. Our 12 years of experience in the healthcare industry has helped us gain enough knowledge and understand all the intricacies associated with medical fraud. We know that every client is different and hence we not only provide services at reasonable rates but also customize them to precisely cater to the requirement of the client. This approach enables the clients to pay exactly for the services they avail.