Healthcare costs number well into the trillions when considering the countless billions of dollars in insurance claims. Most are valid, while others are fraudulent. Those expenses, while significantly smaller, still have significant costs, both financially and perceptions of the overall health care system.
The National Health Care Anti-Fraud Association (NHCAA) reports that the overall monetary losses account for tens of billions of dollars annually. Industry experts see fraudulent acts ranging from three percent to ten percent every year.
Those costs alone result in overall higher premiums and out-of-pocket expenses for consumers. Employers face tough decisions when considering the increase in costs, including the possibility of significantly raising the prices or ending medical benefits for their employees.
While acts of healthcare fraud are considered the exception, not the rule, the financial fallout significantly impacts the medical industry, not to manage the industry’s image.
Common types of fraud committed include:
- Falsely billing services that never took place via stolen patient data or padding claims
- “Upscaling” or “upcoding” expensive services or procedures when less costly services were actually provided
- Unnecessary medical services and testing that result in enrichment via insurance payments
- “Converting” non-covered treatments to those that are medically necessary to increase payments from insurance companies
- Falsifying diagnoses and medical records to support the need for what turns out to be medically unnecessary tests, surgeries, or other procedures
- Unbundling services to falsely claim separate procedures billed individually
- Over-billing patients beyond the co-pay amount for services already prepaid or paid in full
- Taking “kickbacks” for patent referrals
Regardless of the specific allegations, healthcare fraud claims are life-changing and potentially career-ending for a medical professional facing the possibility of license suspension or revocation.