The Most Common Types of Healthcare Fraud Explained


In order to access healthcare services, most Americans rely on medical insurance. While many people take out individual policies or receive insurance through their employment, a significant number are covered by Medicare. In fact, almost 20% of the U.S. population is covered by the Medicare program. 

When medical professionals provide services, they routinely bill insurance companies directly. However, there are instances in which doctors have been accused of insurance fraud. Due to this, it’s essential that you’re aware of common healthcare frauds, Medicare fraud investigation strategies and common errors that lead to accusations. To learn more, take a look at the most common types of healthcare fraud now:

1. Phantom Billing

This is the most common type of healthcare fraud and occurs when physicians bill for services or treatments that haven’t been delivered. In some cases, the alleged patient may have moved to another location or be deceased. Alternatively, physicians may deliver one treatment but bill for another, more expensive, procedure. 

2. Modification of Records

A patient’s medical records should give a true account of their medical history, including any diagnoses or treatments they’ve received. However, unscrupulous professionals may falsify records in order to justify ordering unnecessary tests or treatments. Although these are received by the patient, they are not medically required. In essence, the physician is subjecting a patient to unnecessary tests, procedures or treatments in order to bill for more services. That’s why It is always recommended to have a reliable EMR provider, Click here to learn about Health Wellness EMR.

3.  Inaccurate Billing and Unbundling

Insurance companies and Medicare stipulate that some treatments are ‘bundled’ together under one bill. Typically, this makes it more affordable for patients to access the medical help they need. Healthcare professionals must adhere to these rules when submitting an invoice. If they fail to do so, they can be guilty of Medicare fraud. 

4. Double Billing

Double billing is, perhaps, the easiest type of healthcare fraud to understand. When this happens, Medicare, an insurance company or a patient receives a bill for medical services twice, rather than once. When large companies or schemes, such as Medicare, receive double bills, it may not be picked up straight away, which can result in healthcare professionals being paid twice for their services. 

5. Kickbacks and Commissions

If healthcare professionals receive financial incentives from companies, it’s highly likely to be considered fraud. Receiving a commission or a kickback for using a certain laboratory or referring patients to a particular clinic is certainly not allowed and physicians can face severe sanctions when this behavior is uncovered. 

Dealing with Accusations of Healthcare Fraud

As you can see, there are many different types of healthcare fraud. However, a poorly managed system or a simple human error can result in an invoicing mistake that results in an accusation of fraud, even when no dishonesty or intent is present. 

By understanding how Medicare fraud accusations are dealt with, and obtaining advice from experienced healthcare fraud attorneys, physicians can ensure they have the professional support they need. With the right advice and assistance, healthcare professionals can avoid or rebut such accusations when they need to do so and protect their professional reputation.

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