How to spot health care fraud

Health care fraud is big business. It’s estimated that Medicare and Medicaid fraud alone costs taxpayers more than $100 billion a year in losses, and the losses to private insurance companies are also huge.

That makes it important for health care employees, especially those who work in offices and billing departments, to keep their eyes open for instances of fraud, including the following (relatively) common practices.

Billing irregularities

One of the primary areas where healthcare fraud may occur is in billing practices. Pay attention to discrepancies such as:

• Unbundling: Billing separately for services that are typically billed together.
• Upcoding: Assigning a higher billing code for a service than what was actually provided.
• Phantom billing: Charging for services that were never rendered.

Any pattern of such irregularities could be indicative of fraudulent billing, especially if your employer seems untroubled by the issue (or openly encourages such practices).

Kickbacks

Does it seem like every patient who walks through the door is sent to a neighboring practice to be tested for a heart condition? Are there an unusual number of referrals to a specific specialist? Does the physician seem to be actively “pushing” a certain drug?

If you start to believe that there is a hidden financial relationship between the health care provider and other entities, such as a supplier, pharmaceutical company or another practice, you may be seeing the outward signs of a “kickback” plan in action.

Given the money at stake, it’s not surprising that the federal authorities get pretty intense about suspected health care fraud – and anybody who works in a medical practice that’s involved can get caught up in the wake of an investigation. If you find yourself in a legal “hot seat” because of your employer’s actions, the wisest move you can make is to seek experienced legal guidance.