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Healthcare Fraud – its Various Facets and Impact Medical records are at the center of medical malpractice and personal injury litigation. Easy and ready access to these valuable documents for medical record summary purposes is therefore vital. Healthcare fraud is an ominous reality that has to be exposed and measures taken to prevent it all costs. Healthcare Fraud – a Serious Concern Take the case of a diagnostic imaging facility and its associates that figured in the news recently. These were accused criminally in a multimillion-dollar Medicaid scheme for allegedly paying doctors to send patients to their offices for PET scans, MRIs and other tests that were not medically necessary. For investigation purposes, the offices of the accused were searched by authorities and its records and other assets including expensive equipment was seized, and the facilities shut down. While the attorney of the accused argued that the company was facing many problems – employees could not be paid, patients couldn’t gain access to their medical records, and so on – the Deputy Attorney
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General made it clear that the defendants are facing grave criminal charges and so the seized assets could not be released. This was the second time that one of the companies involved was being accused of Medicaid fraud. According to the NHCAA (National Health Care Antifraud Association), financial losses stemming from healthcare fraud amount to tens of billions of dollars each year. Such fraudulent practices lead to higher premiums and out-of-pocket expenses for consumers and reduced coverage/benefits. Simultaneously, for the government and private employers it increases the cost of providing coverage benefits for employees. Healthcare fraud can be devastating. • People are subjected to unnecessary and even dangerous medical procedures. • Considerable financial loss. • Genuine insurance information may be used to submit fraudulent claims. • Medical information is compromised. Fraudulent Medical Practices to Watch out for Providers that indulge in healthcare fraud are very few, but they tarnish the image of the vast majority of sincere and caring providers. How do fraudsters carry out their scheme? • Up-coding – This involves billing for a higher-priced treatment than what was actually provided – and the danger? The patient is diagnosed to have a more
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serious condition that would be consistent with the code billed. Claiming reimbursement for services that were not provided – For this, dishonest providers use genuine patient information extracted through identity theft, or charge for procedures/services that did not take place. Performing medically unnecessary services – Done purely from the point of view of generating insurance payments, these can be very dangerous to the patients. Treatments that are not covered are misrepresented as medically necessary, covered procedures. Unbundling or claiming reimbursement for each step of a procedure as if it were a separate procedure. Justifying medically unnecessary treatments provided by falsifying the patient’s diagnosis. Accepting bribes for patient referrals. Billing a patient more than the co-pay amount due for services that were paid in full or prepaid by a managed care contract plan. Waiving patient deductibles/co-pays for medical or dental care and over-billing the payer or benefit plan.
Fraudulent medical claims are exposed through comprehensive medical record chronology and summary. However, until and unless the discovery of fraud is made, the situation is rather grave for the patient as well as payer. The false diagnosis remains part of the patient’s medical history at least in the records of the insurer.
MOS Medical Record Reviews
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Criminal Offence Carrying a Stiff Penalty The HIPAA has established healthcare fraud as a federal criminal offense with the basic crime carrying a federal prison term of up to ten years in addition to significant financial penalties (United States Code, Title 18, Section 1347). If the fraud results in the injury of the patient, the prison term can double up to 20 years. The person responsible can be sentenced to life in federal prison if the patient dies as a result of the fraud. Congress also mandated the establishment of a nationwide Coordinated Fraud and Abuse Control Program to organize federal, state and local law enforcement efforts against medical fraud, and also to coordinate and share data with private payers. Many states have strengthened their insurance fraud laws and penalties. Health insurers should take steps meet established standards of fraud detection, investigation and referral.