10 popular health care provider fraud schemes


health care fraud and abuse articles

Detra Wiley Pate was sentenced to months in federal prison for multiple counts of health care fraud, conspiracy to commit health care fraud, and aggravated identity theft. Read More. Press Release. Allegations of fraud by Solantic, a chain of Florida urgent care clinics owned in part by Florida Republican Gubernatorial Candidate and former HCA CEO Rick Scott, have been forwarded to the U.S. Department of Health and Human Services for possible investigation. Dec 01,  · A former health care clinic consultant and Medicare biller has been sentenced to a little more than 11 years in prison, and ordered to pay a $, fine, for her role in a $63 million healthcare fraud scheme involving a now-defunct Miami health provider, the Department of Justice announced earlier this week. Full story. About this gallery.

Biggest healthcare frauds in Running list | Healthcare Finance News

Most medical providers are honest and work hard to improve their patients' health. However, a few want to illegally increase the size of their bank accounts. Learn some of the basic health care provider schemes and how to deter them from taking some easy money. Patients with Alzheimer's disease were sitting unsupervised inside a small room of a medical psychological care facility watching the movie "Forrest Gump" for the umpteenth time.

Granted, it's a great movie, but each time the patients sat in front of the tube watching it, health care fraud and abuse articles, the facility submitted insurance claims for providing "group therapy. I discovered this fraud during my investigation of the facility.

It's just one of a long list of crimes committed by a handful of crooked medical providers. Essentially, fraud in health care is just like in any other industry: Fraudsters with the means and opportunity take full advantage to unjustly profit. Health care crooks inside and outside the industry include patients, payers, employers, health care fraud and abuse articles, vendors and suppliers, and providers, including pharmacists.

Organized crime rings and computer hackers also play roles in committing health care fraud. The difference between the health care realm and many other industries is its huge, alluring, easy pile of cash.

The CMS projects U. Over the period ofhealth spending is projected to grow at an average rate of 6. Over the years, I've found investigating fraud committed by health care providers, facilities and institutions to be extremely fascinating, challenging and rewarding. Most associate those individuals and entities with only doing good and helping others.

Although that's true of most health care providers and institutions, others do "go south. In this article, I describe 10 of the common health provider fraud schemes I've found, and I include some cases I've investigated. This list definitely isn't inclusive, but it will get you started on understanding how providers can be tempted to defraud a lumbering system, health care fraud and abuse articles.

It makes sense that if a fraudster would commit any of the other schemes listed above, which takes a bit of brainpower and effort, they might as well throw in some extra dates and codes on the claim forms to try to make some real easy money. During the early stages of a health care fraud examination or investigation, health care fraud and abuse articles, I identify the reported dates of service listed on the claim forms and then look for any documentary evidence that the patients were at the facility on those dates.

I first check a patient's medical file. If I find no documentation, I check the facility's sign-in logs. If there's nothing there, I check the appointment calendars. Of course, you try to be fair and objective.

Our ability to empathize with others including suspects helps us treat them fairly and allows us to better understand their situations. So, I realize that records can be misplaced, and, occasionally, somebody might forget to write something down.

However, a pattern of billing for services and care with no supporting documentation is unacceptable and unlikely to be coincidental. Healthcare providers' excuses for missing documentation are sometimes almost humorous.

Some providers have blamed non-existing floods, fires and even Y2K remember the "Year Problem" or the "Millennium Bug"? I keep waiting for someone to tell me his dog ate the documentation. Documents alone don't usually prove intentional wrongdoing. Fraud examiners and investigators also will need to locate witnesses who can — and are willing to — truthfully relate what they know about the fraud. That's when well-planned interviews come into play.

Often interviewing the patients whose names are listed on the questionable claim forms can clear health care fraud and abuse articles up. They know whether they visited the doctor or not, and — unless they were unconscious when providers examined them — they'll have a pretty good idea what services they received.

However, sometimes patients have foggy memories or medical issues that impair their memories of past visits. And the claims might be several years old. In Medicare investigations, an added dilemma is that the elderly patients sometimes die before they're interviewed or before the cases go to trial.

Most people in the medical field are honest and ethical, so fraud usually will health care fraud and abuse articles their consciences. Sometimes they'll just quit their jobs because they don't want to be part of illegal activities. But for those who remain on the job, they often won't tell what they know until they're confronted.

I've found it's usually best to interview employees and former employees of medical facilities at their homes or at least away from the facilities. Make sure you leave your business card with them, even if they don't want to talk yet. Billings for services and care not rendered often make for simple cases to present in court because the scheme is so basic that even half-asleep jurors can understand it.

Even when I'm putting together a health care fraud case that also includes more complex fraud schemes, if I find evidence of billing for services with no supporting documentation, I often include those first in my summary report. During one fraud examination Health care fraud and abuse articles conducted, an allergy doctor was providing a treatment, which was considered experimental and therefore not approved by government health care plans or other insurance companies.

With a few strokes of a pen or taps on a keyboard, the allergy doctor submitted claim forms and still got paid for utilizing the experimental treatment. She accomplished this by calling it and coding it something else that was covered by insurance plans and policies. Like most other criminals, this doctor rationalized her wrongful actions. She believed she was providing a useful service to her allergy-suffering patients and that it wasn't her fault the government and insurance companies hadn't yet approved the experimental treatment.

Keep in mind that most patients are only concerned with two things: getting healthy or finding relief from their suffering and how much they personally have to pay out of their own pockets for medical services. Because the insurance companies are footing the bills or most of thempatients usually have no qualms as long as they are regaining their health.

In the allergy clinic case, the doctor only gave a few health care fraud and abuse articles the experimental treatment; most received approved care.

But I noticed something unusual when I reviewed the patients' files: The insurance claim forms showed that many patients were treated at the allergy clinic four or five days per week Monday through Friday, health care fraud and abuse articles. I remember thinking, "I wouldn't come here that often even if they were giving away free lunches. Obviously, my case was getting stronger. Providers might make more money by reporting they visited with or and treated the same patient on two separate days rather than one day.

Each "office visit" is usually considered a separate billable service. Often the services the fraudsters list on claim forms are actually provided, but the dates are false because it's more profitable for the providers. So check to assure that the patients' medical file documentation matches the dates of service listed on the claim forms. Focus on the "date of service" not the date the claim form was signed or submitted because those dates may be several days after the service was provided.

Let's get back to that allergy clinic. When I interviewed patients at their homes, many who previously told me they only received injections twice a week, also told me they only went to the allergy clinic once a month. The patients said that the allergy clinic workers would hand each of them a bunch of syringes filled with antigens and tell them to inject themselves in their homes!

Because I'm a bit shy of needles, and the thought of injecting myself makes me cringe, I wondered if insurance companies would knowingly approve self-injections away from the allergy clinic. A specialist from one of the insurance companies told me that it and most other companies didn't accept self-injection as a reimbursable expense.

The specialist said medical providers should monitor patients for several minutes after injections to ensure the patients don't have adverse reactions. I examined the claim forms and found that the allergy doctor had reported that the injections were given at the allergy clinic. I started to wonder if the allergy clinic was doing anything legally. I confronted the allergy doctor with the evidence, and she claimed she didn't know this type of billing was improper.

I asked how she determined the day of the week the patients injected themselves when preparing the claim forms, and the doctor said that she just guessed. I thought it was more than a coincidence that she always "guessed" the injections were given Monday through Friday when the allergy clinic was open for business and not Saturday, Sunday or holidays when the allergy clinic was closed.

I think she knew that billing for Sunday injections would health care fraud and abuse articles raised red flags at the insurance companies. In other cases, I investigated physicians who had billed for services provided in their offices that were located in the U.

These were closer to "no supporting documentation" fraud, but because the physicians didn't take their patients with them on their trips, those claims were really far off! It's a scary thought that somebody might impersonate a physician and bill for treatment, but it does happen. I've conducted numerous investigations in which medical doctors signed insurance claim forms showing that they had provided all the care but in reality, lesser-educated mental health professionals actually conducted the therapy.

In these cases, the affected insurance companies would still have paid for the care provided by the lesser-educated therapists as long as they were licensedbut they would have paid less. For example, I learned that licensed clinical social workers are often reimbursed less than physicians. In another investigation, I discovered that a psychological care facility even hired people to be therapists who had never been trained to provide those services.

One of those unlicensed providers told me he was hired solely because he was a friend of the owner. The facility also had hired a part-time doctor to come in the office two days a week to review treatment files and sign claim forms. During an interview, I asked the doctor why he had signed the claim forms when he didn't personally provide the treatment.

The doctor was almost defiant when he said he was permitted to do so because he was the supervising physician, health care fraud and abuse articles. I next asked him if he knew that some of the therapists weren't licensed to provide therapy.

The doctor shook his head and asked me, "Well then, why the heck are they working here!? He also said he didn't realize that the insurance companies paid more just because a physician signed the claim forms.

The doctor also admitted that he normally wasn't on the premises when the lesser-educated "therapists" provided the care, but he rationalized signing the claim forms because he reviewed the patient files before signing. The doctor sadly looked at me and said, "I guess I'm the goat. I looked forward to interviewing the owner; however, he didn't offer any valid excuses for his crimes, health care fraud and abuse articles. He did say he didn't think he should go to jail because he was extremely overweight.

Most government health care plans and insurance companies don't allow medical providers or facilities to waive patients' deductibles or co-payments, health care fraud and abuse articles. The rationale may be that if patients have to pay something to see doctors, they'll only seek care if they really need it.

Perhaps it's also a way to offset some of the expenses. Regardless, some providers do waive patients' deductibles or co-payments and then submit other false claims to insurance companies to make up the dollar health care fraud and abuse articles. Truly unscrupulous providers also will add a bunch of other false services to the claim forms to increase their illegal gains knowing that the patients are unlikely to complain because their co-payments and deductibles were waived.

Patients might also have copies of receipts issued from medical facilities or perhaps even cancelled checks or credit card receipts showing what they paid. So keep in mind that it may also prove beneficial to interview patients plus current and former medical facility employees. It's been my experience that it's usually tactically smarter to try to interview former employees before interviewing current employees.


10 Healthcare Fraud Cases Making Headlines


health care fraud and abuse articles


Dec 01,  · A former health care clinic consultant and Medicare biller has been sentenced to a little more than 11 years in prison, and ordered to pay a $, fine, for her role in a $63 million healthcare fraud scheme involving a now-defunct Miami health provider, the Department of Justice announced earlier this week. Full story. About this gallery. Allegations of fraud by Solantic, a chain of Florida urgent care clinics owned in part by Florida Republican Gubernatorial Candidate and former HCA CEO Rick Scott, have been forwarded to the U.S. Department of Health and Human Services for possible investigation. Sep 16,  · In the Health Insurance Portability and Accountability Act of (HIPAA) established the Health Care Fraud and Abuse Control program (HCFAC). In , HHS and the Attorney General allocated $,, to HCFAC to fight healthcare fraud and vjesnikws.ga by: