Healthcare fraud involves intentionally falsifying information for payment of healthcare services or equipment. It is committed by patients, physicians, and medical equipment providers, leading to higher costs. Fraud can involve falsifying diagnoses, upcoding, unnecessary stages of billing, changing co-payments, and selling drugs for profit. Reporting suspicions of fraud can help reduce fraudulent activity.
Healthcare fraud is the crime of intentionally falsifying information to be provided to an entity for the express purpose of receiving payment for healthcare services or equipment. It is considered a “white collar” crime. The targeted entity is almost always a health insurance company, but it can also be a branch of the government that provides health care. There are several ways in which fraud in medical services can be committed. Most of them involve falsifying information about an insurance claim.
Patients, physicians, and medical equipment providers have been found to knowingly participate in healthcare fraud, which contributes to higher costs of healthcare services, equipment, and prescribed drugs. The criminal actions of such persons could be profitable for the patient, the doctor or other healthcare professional or the provider of medical services. A form of healthcare fraud is committed when a patient’s diagnosis is falsified to justify medically unnecessary tests, treatments, procedures, and even surgery. For example, medical insurance companies generally don’t offer coverage for cosmetic surgery, but a cosmetic surgeon might falsify a claim with an insurance company to receive payment.
Other ways some dishonest people commit healthcare fraud involve filing claims for services, treatments, or procedures that cost more than they actually performed. This is sometimes achieved by a technique known as upcoding. Codes for services, treatments and procedures that are closely related to a specific disease or condition but are priced differently may be intentionally “scrambled” when reported on claims. Healthcare fraud also occurs when billing for a single treatment, procedure, or service is done in unnecessary stages, leading to multiple payments for what should have been paid in one payment.
Changing the patient’s co-payments and deductibles set by the coverage insurance company is another form of healthcare fraud. Sometimes these payments are reversed and the request changes to raise more money than should be raised to cover the patient’s out-of-pocket expenses. Healthcare fraud has also spread to the black market. When a person obtains a fully covered prescription for the purpose of selling the drug for profit, he or she is committing medical fraud. Healthcare recipients can help reduce fraudulent activity by reporting their suspicion of fraud, which can usually be done anonymously.
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