What can be done about health care fraud?

Health care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Fraudulent health care schemes come in many forms.

Doctors and doctors' offices schemes of fraud can include:

  • individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit;
  • billing by practitioners for care that they never rendered;
  • filing duplicate claims for the same service rendered;
  • altering the dates, description of services, or identities of members or providers;
  • billing for a non-covered service as a covered service;
  • modifying medical records;
  • intentional incorrect reporting of diagnoses or procedures to maximize payment;
  • use of unlicensed staff;
  • accepting or giving kickbacks for member referrals;
  • waiving member co-pays; and
  • prescribing additional or unnecessary treatment.

      Patients can commit health care fraud by:

      • providing false information when applying for programs or services,
      • forging or selling prescription drugs,
      • using transportation benefits for non-medical related purposes, and
      • loaning or using another’s insurance card.

      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.

      Congressional legislation requires that health care insurance pay a legitimate claim within 30 days. The Federal Bureau of Investigation, the U.S. Postal Service, and the Office of the Inspector General all are charged with the responsibility of investigating health care fraud. However, because of the 30-day rule, these agencies rarely have enough time to perform an adequate investigation before an insurer has to pay.

      A successful prosecution of a health care provider that ends in a conviction can have serious consequences. The health care provider faces incarceration, fines, and possibly losing the right to practice in the medical industry.

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