As people die from lack of health care here in the USA - and, that's ought to be a crime - I am especially incensed by health care fraud including bill padding. Please share your experience!
PERSONAL
EXPERIENCE:
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After
my aunt’s death, my sister received receipts for medical services rendered after her death.
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Some
MD’s keep a list of all Medicare patients being seen by PA’s or MSN’s. Then,
they look into the room, ask a brief question and bill Medicare for both the PA or the MSN and a physician consultation.
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A
clinic advertises a “Headache Clinic.” This consists of a neurologist and a
“float nurse” – not even a HA specialist. The float nurse spends about an hour
and 45 mins administering a questionnaire that could be filled out by the
patient alone. The neurologist spends about 10 ministering administering a very
simple neuro check – and, they bill $700.00. No technology involved. I
challenged this bill, even though my insurance was paying, and got it reduced.
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Doctors
who prescribe antibiotics for viruses and then have patients come back for follow
up – for the common cold.
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Clinics
have “quotas” – they want their doctors to see a certain number of patients/week.
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Clinics
give bonuses for doctors seeing the highest numbers of patients.
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Clinics
encouraging doctors to prescribe medication that require follow-up visits –
such as narcotics.
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Hip
replacement patients were not purchasing the optional personal care items
(which were unnecessary or could be bought less expensively at local stores) so
the items were added to the room charge.
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Patients
are required to be seen by a PA or nurse who is unable to answer basic
questions and must then also be seen by an MD. This should be a cost savings,
but is used to “double book” or bad bills instead.
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Doctors
bill for every second of your time – even the time spent standing in the hall
way.
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Patients
cannot compare costs between clinics because the billing is so complicated.
Even when you are seeing a doctor for a simple reason and there will be no
testing or technology involved, clinics claim that they cannot tell you in
advance how much you will be charge.
What Does Health Care
Fraud Look Like?
The majority of health
care fraud is committed by a very small minority of dishonest health care
providers. Sadly, the actions of these deceitful few ultimately serve to sully
the reputation of perhaps the most trusted and respected members of our
society-our physicians.
The most common types
of fraud committed by dishonest providers include:
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Billing for services that were never rendered-either by using
genuine patient information, sometimes obtained through identity theft, to
fabricate entire claims or by padding claims with charges for procedures or
services that did not take place.
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Billing for more expensive services or procedures than were
actually provided or performed, commonly known as "upcoding"-i.e.,
falsely billing for a higher-priced treatment than was actually provided (which
often requires the accompanying "inflation" of the patient's
diagnosis code to a more serious condition consistent with the false procedure
code).
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Performing medically unnecessary services solely for the purpose
of generating insurance payments-seen very often in nerve-conduction and other
diagnostic-testing schemes.
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Misrepresenting non-covered treatments as medically necessary
covered treatments for purposes of obtaining insurance payments-widely seen in
cosmetic-surgery schemes, in which non-covered cosmetic procedures such as
"nose jobs" are billed to patients' insurers as deviated-septum
repairs.
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Falsifying a patient's diagnosis to justify tests, surgeries or
other procedures that aren't medically necessary.
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Unbundling - billing each step of a procedure as if it were a
separate procedure.
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Billing a patient more than the co-pay amount for services that
were prepaid or paid in full by the benefit plan under the terms of a managed
care contract.
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Accepting kickbacks for patient referrals.
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Waiving patient co-pays or deductibles for medical or dental
care and over-billing the insurance carrier or benefit plan (insurers often set
the policy with regard to the waiver of co-pays through its provider
contracting process; while, under Medicare, routinely waiving co-pays is
prohibited and may only be waived due to "financial hardship").
What's the Problem?
Health care fraud perpetrators steal billions of dollars
each year from Federal and State governments, from American taxpayers, and some
of our country’s most vulnerable citizens. Fraud drives up the costs for
everyone in the health care system, in addition to hurting the long term
solvency of the Federal health care programs, like Medicare and Medicaid, upon
which millions of Americans depend.
Health care fraud can occur in many ways. One example is
when an insurer (e.g., Medicare or a private health care insurance company) is
intentionally billed for services or supplies that were never provided. Other
examples of fraud include, but are not limited to the following:
·
A health care provider bills for services or supplies (e.g., home
health services, diabetic supplies, hospital visits, exams) that were never
provided
·
A health care provider bills an insurer for services or treatments
that are medically unnecessary and, in some cases, potentially even harmful to
the patient (e.g. power wheelchairs, therapy sessions, ambulance transports)
·
Patients’ insurance numbers are stolen and sold to criminal
organizations and then used to bill for health care services, supplies, or
equipment that were not necessary or never provided
·
A health care provider is paid bribes to refer patients for
services and treatments which may be medically unnecessary or substandard (e.g.
mental health services, physical therapy)
·
An insured individual sharing their health insurance information
with someone else so that the uninsured person can obtain health care services
under the insured’s name.
TEN COMMON HEALTH CARE PROVIDER
FRAUD SCHEMES
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Billing
for services not rendered.
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Billing
for a non-covered service as a covered service.
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Misrepresenting
dates of service.
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Misrepresenting
locations of service.
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Misrepresenting
provider of service.
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Waiving
of deductibles and/or co-payments.
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Incorrect
reporting of diagnoses or procedures (includes unbundling).
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Overutilization
of services.
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Corruption
(kickbacks and bribery).
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False
or unnecessary issuance of prescription drugs.
HEALTH CARE FRAUD:
When a
health care fraud is perpetrated, the health care provider passes the costs
along to its customers. Because of the pervasiveness of health care fraud,
statistics now show that 10 cents of every dollar spent on health care goes
toward paying for fraudulent health care claims.
