Medicare fraud might involve some shady telemarketer calling older adults and trying to trick them into giving their information out over the phone. It might involve someone posing as their older sibling to receive healthcare.
However, the most expensive and common form of Medicare and Medicaid insurance fraud involves provider fraud. Some healthcare providers that accept government insurance programs commit overt acts of fraud. There have been cases of doctors providing unnecessary medical procedures just so they could bill for them, for example, or billing policies of patients who are already dead.
Compared with such egregious misconduct, what the billing staff at your medical facility does might seem like a minor issue. However, two common billing practices can easily lead to fraud charges for the person who enters the charge and other workers that that medical practice.
There are special billing codes designating hundreds of different medical procedures. Many of them take roughly the same amount of time and may even involve the same equipment or medical conditions.
Upcoding is a form of fraud that involves billing for a different procedure than what the medical facility actually provided. It may seem like a victimless crime because the patient received treatment and the facility provided that care, but the taxpayers are ultimately the ones who must pay the extra money for that more expensive, upcoded charge. Patients may recognize upcoding if they review their statements and could potentially bring the attention of authorities to the issue.
Insurance companies set specific reimbursement rates for different treatments when they negotiate contracts with individual care providers.
There are certain things that often go together, such as the administration of local anesthesia before a minor surgical procedure, and the insurance company may pay slightly less for frequently-combined medical services than for each of those treatments when billed separately. If the insurance company or program negotiated a discounted cost for commonly-combined services, it is actually fraud to charge more by intentionally billing for each step of the treatment separately.
These minor changes to how the company handles billing could lead to thousands of dollars in revenue and possibly federal criminal charges against the people involved. Learning more about white-collar criminal charges can help those facing charges or worried about their circumstances.