Preview

Billing Fraud

Good Essays
Open Document
Open Document
1005 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Billing Fraud
Medical Billing Fraud

What is Medical Billing Fraud? It is an attempt to fraudulently obtain payments from insurance carriers. Medicare and Medicaid are the most susceptible to fraud because of their payment arrangements. Fraud in medical billing cost tax payers and medical providers millions of dollars annually. In 1996, HIPPA established the Health Care Fraud and Abuse Control Program (HCFAC) to help combat medical billing and health care fraud. Fraud is an act done with the knowledge that you are doing wrong.
Fraud is the intentional deception and misrepresentation that is to result in an unauthorized benefit. Abuse is the charging of services that are not medically necessary. False claim schemes are the most common type of health insurance fraud. The reasoning to do fraud is to obtain undeserved payments for claims. Some schemes to watch out for are: * Billing for services, procedures and/or supplies that were not used. * Unbundling of claims. This is billing separately for procedures that are covered by a single fee. * Double billing. This is charging more than once for the same service. * Upcoding. This is charging for more complex services than was performed. * Miscoding. This is using code numbers that don’t apply to the procedure. * Kickbacks. This is receiving payments for other benefits for making a referral. * Inappropriate or Excessive testing. This is billing for tests that didn’t happen or billing for tests that are more in depth then what was actually done. * Inflated pricing of drugs. * Scheduling unnecessary patient visits. * Self-referrals between physicians. * False diagnosis. * Using wrong modifiers.
Insurance companies can also be involved in medical billing fraud. Insurance companies sometimes hire medical billers and coders to help manage claims. The insurance company can have the billers and coders make adjustments or they can deny claims incorrectly so they can lower the payment amounts.

You May Also Find These Documents Helpful

  • Good Essays

    Medical Identity Theft

    • 638 Words
    • 3 Pages

    Medical identity theft is when someone uses your personal identity to use your medical insurance benefits to get free medical services and/or make false claims to gain financial assistance by using your identity. Medical identity theft accounts for 3 percent of identity theft crimes, or 249,000 of the estimated 8.3 million people who have had their identities stolen in 2005, according to the Federal Trade Commission. It is estimated that people who are affected by this crime are left with $40,000 + in bills for services they never used. Medical identity theft can take place in private doctor’s offices, hospital’s, or pharmacy’s. A single person or a group could be involved in this crime. Some people fear that with the electronic medical records from paper that it may be easier to get peoples medical identity. Many people don’t even realize that they have been a victim of this crime until months to years down the road.…

    • 638 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Medicare Fraud

    • 335 Words
    • 2 Pages

    Medicare Fraud is presented in many different ways. Some examples of Medicare Frauds are: A healthcare provider bills Medicaid for services and equipment you never received, someone uses another person’s Medicare card for services or equipment, a company offers a Medicare drug plan that hasn’t been approved by Medicare, a company uses false information, etc. (www.medicare.gov). Medicare fraud causes increases in taxes, decreases in Medicare benefits, and an overall feeling of distrust in the health system among citizens. .…

    • 335 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    the way they do business. Over the last ten years, the Federal government has dramatically increased its enforcement activities, both criminal and civil, in an effort to essentially force healthcare providers to improve the quality of care they provide. "Compliance," in contrast, refers to a separate category of risk involving reimbursement and billing issues. In its role as the largest healthcare payor in the nation, the Federal government has traditionally taken the lead in investigating and prosecuting healthcare providers who illegally obtain payment from the various federally funded healthcare programs. The purpose of the compliance function, as described by the Federal government, is to insure that facilities are in compliance with the various billing and reimbursement requirements intended to prevent such fraudulent billing (Schindler, 2009).…

    • 441 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    There a several reasons a medical claim may be denied by the payer. If the patient has other primary medical insurance or, the patient as a workers’ compensation claim. or, an automobile claim there is specific information that is required. The scheduler has to ensure they have the patients’ correct and updated information. Workers’ Compensation and auto accident claims require the patients claim number, adjusters’ name, and all services require preauthorization. An error in relation to this example is considered a billing error. Another example of a billing error is the absence of a referral on file because most HMO’s require a referral. An example of a registration error would be that the patients’ insurance information changed and no longer covers a service provided (2008).…

    • 292 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Working with Medicaid

    • 396 Words
    • 2 Pages

    Depending on what state a person lives in, those enrolled in the Medicaid program may be treated by a provider of their choice or it may restrict patients to a network physicians. Enrollees may have to receive all services through their primary care provider that is responsible for coordinating and monitoring their care. Those that need to see a specialist may need to obtain a referral from their PCP or Medicaid will not pay for the services. If a Medicaid enrollee wants to receive a service that is non-covered, the enrollee must pay for the non-covered services prior to the services being rendered. Medicaid recipients can also be billed if the physician informed the patient before the service was performed that the procedure/service would not be covered by Medicaid, the physician has an established written policy for billing non-covered services that applies to all patients, the patient is informed in advance of the estimated charge for the procedure and agrees in writing to pay the charge. If the physician has reason to believe that a service will not be covered, the patient must be informed in advance and given a form to sign acknowledging this. However, some states may require the enrollee to pay a small co-pay for covered services.…

    • 396 Words
    • 2 Pages
    Good Essays
  • Good Essays

    Medicare Persuasive Essay

    • 649 Words
    • 3 Pages

    believe fraud is much more common in Medicare than in it is in payments by…

    • 649 Words
    • 3 Pages
    Good Essays
  • Satisfactory Essays

    Health Care Fraud continues to be a huge issue across the board for health care providers, insurance companies, employers, employees, and the everyday common individual. Fraud affects every one is one way or another. Because medical fraud causes billions of dollars each year it forces insurance companies to have higher premiums resulting in a lot of out of pocket expenses. This then becomes a domino effect for companies by reducing employees benefits. resulting in the increase for all business owners and their overall expenses.…

    • 181 Words
    • 1 Page
    Satisfactory Essays
  • Good Essays

    Accounting Fraud

    • 654 Words
    • 3 Pages

    In criminal law, fraud is the crime of deliberately deceiving another person or company in order to damage them, usually for personal gain. Defrauding people of money is the money is the most common type of fraud. Some types of fraud include false accounting, check fraud, and Internet fraud.…

    • 654 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Smps

    • 4309 Words
    • 18 Pages

    M. Anas, N. Javaid, A. Mahmood, S. M. Raza, U. Qasim‡ , Z. A. Khan§…

    • 4309 Words
    • 18 Pages
    Good Essays
  • Good Essays

    Tender

    • 597 Words
    • 3 Pages

    4. Disputes over payments, either payments from the client to your organisation or payment from your organisation to…

    • 597 Words
    • 3 Pages
    Good Essays
  • Good Essays

    patient privacy

    • 979 Words
    • 4 Pages

    Too often, unauthorized people succeed in extracting protected information from health care providers. Invasion of privacy also affects noncelebrities, when anyone seeks health information the patient has not chosen to share. More often, though, scam artists seek patients' billing information for financial gain. The patient's insurance identifier is then used by an uninsured person to obtain medical services or by a fraudulent health care provider to bill for medical services that were never rendered. Data security breaches and medical identity theft are growing concerns, with thousands of cases reported each year. The Centers for Medicare and Medicaid Services (CMS) tracks nearly 300,000 compromised Medicare-beneficiary numbers.2 The Office for Civil Rights has received more than 77,000 complaints regarding breaches of health information privacy and completed more than 27,000 investigations, which have resulted in more than 18,000 corrective actions.3…

    • 979 Words
    • 4 Pages
    Good Essays
  • Good Essays

    Fraud detection systems examine medically impossible procedures, services billed while the patient is hospitalized, non-covered services that were paid, provider billing errors, provider up-coding and miscoding, and duplicate services across providers and claim types.…

    • 409 Words
    • 2 Pages
    Good Essays
  • Good Essays

    Many health care organizations get into trouble with abusing medicare by charging for services that was never had been rendered. Medicare fraud has cost Americans and the federal government close to a billion dollars. In an article by star telegram dated October 5th 2012 there were 14 health care professionals arrested and charged with medicare fraud in surrounding Texas cities. Apparently these health care professionals were charging medicare beneficiaries for services that were not rendered at the time of care. Some of these services were unnecessary medical services as in section 40.1.4 states in the Centers of Medicare and Medicaid Services medicare processing…

    • 805 Words
    • 4 Pages
    Good Essays
  • Better Essays

    Occupational Fraud!

    • 1069 Words
    • 5 Pages

    Fraud is categorized according to type, and the three types that we want to examine here, among others falls under the category of fraudulent disbursements; they are billing schemes, check tampering schemes, and payroll schemes.. This category of fraud is said to be the most prevalent form of asset misappropriation. They are said to be committed when an employee uses his position effect payments for some transactions that are not supposed to be paid for.…

    • 1069 Words
    • 5 Pages
    Better Essays
  • Powerful Essays

    No precise legal definition of fraud exists; many of the offences referred to as fraud are covered by the Theft Acts of 1968 and 1978. Generally, the term is used to describe such acts as deception, bribery, forgery, extortion, corruption, theft, conspiracy, embezzlement, misappropriation, false representation, concealment of material facts and collusion. For practical purposes fraud may be defined as the use of deception with the intention of obtaining an advantage, avoiding an obligation or causing loss to another part. (Internal Audit, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK)…

    • 7542 Words
    • 31 Pages
    Powerful Essays