Healthcare Fraud

Healthcare fraud affects everyone. It impacts the quality of all healthcare and results in higher costs to the consumer, employer and taxpayer. Losses due to healthcare fraud cost our country billions of dollars a year. Healthcare fraud also harms people individually when services are recommended that are either unneeded or inappropriate or by providers who are not certified to provide such services.

The most common types of healthcare fraud that have been identified lately include:

  • Services Not Rendered: Claims submitted for services that never were received or delivered or were not medically necessary for the patient.
  • Top Providers and Top Prescribers: Top prescribers and providers are identified as prescribing or providing more services or items than others in the same professional peer group within their respective area or regions.
  • Drug Diversion: Drug diversion is a criminal act involving the unlawful distribution of prescription drugs.
  • False Front Providers: These are fictitious clinics, laboratories or other fake providers that bill for items or services not delivered. Many are identified as empty “shell” offices generating false claims.
  • Upcoding: Billing health care plans for more costly services or items versus what was delivered or received by the patient. This is done by billing a different level code to obtain a higher reimbursement

The Affordable Care Act of 2010 improved healthcare fraud enforcement. Among other things, this law made it easier for the government to get back money obtained by fraudulent practices, made obstructing a fraud investigation of a crime and increased penalties for healthcare fraud offenses.