Health Care Fraud Explained


What is health care fraud?

The term health care fraud refers to any kind of fraud that is related to health care and is carried out by medical professionals, patients, or anyone who aims to intentionally deceive the health care system. According to the FBI, health care fraud can cost American taxpayers an estimated amount of $80 billion every year. Health care fraud has serious consequences for anyone, as it can raise health insurance premiums, subject patients to unnecessary medical procedures and medication, as well as increase taxes.

Types of healthcare fraud

Health care fraud is a very broad term that describes many types of scams. You can find a few scams explained below but generally, all scams that have something to do with health care can be referred to as health care fraud.

  • Unbundling.

Unbundling or double-billing is a type of fraud that involves issuing multiple bills for the same service.

  • Billing for services that weren’t provided.

Also known as phantom billing, this type of fraud involved issuing a bill for services or supplies the patient never received.

  • Upcoding.

This refers to a type of fraud that bills insurance programs for services and supplies that are more expensive than those actually received.

  • Unnecessary services.

This refers to a type of fraud that involves issuing bills for services and supplies that were not necessary to treat a patient’s condition.

  • Misrepresenting dates of service.

This refers to a type of fraud that involves health care providers falsely reporting that they treated a patient on two or more separate days instead of just one. Since each visit is usually charged separately, health care providers are able to profit by simply misrepresenting dates of services.

  • Health care worker impersonation.

This refers to providing medical services and issuing bills without a license.

  • Filing claims for services that were not received.

This type of fraud refers to consumers filing claims for services and/or medication that they did not actually receive.

  • Identity theft.

This refers to using someone else’s health insurance or allowing someone else to use yours.

  • Prescription medication forgery.

This refers to writing or using forged prescriptions. Prescription fraud is a very serious crime that costs a lot of money to hospitals, insurance companies, taxpayers, etc. However, it also has serious consequences for human life as thousands of people die from drug overdoses every year.

  • Kickbacks.

Kickbacks are essentially bribes. It includes giving medical professionals cash, lavish gifts, jewelry, vacations, etc., to persuade them into providing certain medical services. For example, giving cash in exchange for a particular test when doing one is not required to treat a patient’s condition.

Avoiding health care fraud

  • Keep your health insurance information safe.

Health insurance information should be protected just like any other sensitive document/item. Do not share your insurance information with anyone and be careful when at the doctor’s office or pharmacy.

  • Regularly review your explanation of benefits. 

Make sure to regularly check your explanation of benefits and pay particular attention to dates, locations, services you were billed for, etc. If something does not match, contact your health insurance provider as soon as possible.

  • Be wary of free services.

If when you receive a free healthcare-related service you are asked to provide your health insurance information, it’s likely that the service is not actually free. The service could be fraudulently charged to your insurance.

  • Ask questions when receiving medical services.

Do not be afraid to ask about the medical services you receive, why they were necessary, and what their cost is.

Reporting health care fraud

Patients or health care providers are encouraged to report any kind of health care fraud to authorities, particularly the FBI if in the US, if they become a victim of it or notice it happening.

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