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What Are the Most Prevalent Health Care Fraud Schemes?

The FBI’s “Financial Crimes Report to the Public” offers unique insight into the investigation and prosecution of health care fraud in California and across the country. It specifically highlights some of the most common health care fraud schemes investigated by the FBI and other law enforcement agencies.

Some of the most prevalent medical fraud schemes include:

Upcoding of Services: This type of scheme involves a billing practice where the health care provider submits a bill using a procedure code that yields a higher payment than the code for the service that was truly rendered. The upcoding of services varies according to the provider type. Examples of service upcoding include billing a routine, follow-up doctor’s office visit as an initial or comprehensive office visit or billing a 30-minute session as an hour session.

Upcoding of Items: A medical supplier is upcoding when, for example, the supplier delivers to the patient a basic, manually propelled wheelchair, but bills the patient’s health insurance plan for a more expensive motorized version.

Duplicate Claims: A duplicate claim usually involves a certain item or service for which two claims are filed. In this scheme, an exact copy of the claim is not filed a second time; rather, the provider usually changes a portion, most often the date of service on the claim, so that the health insurer will not realize the claim is a duplicate. In other words, the exact claim is not filed twice, but one service is billed two times, in an attempt to be paid twice for one service.

Unbundling: This is the practice of submitting bills in a fragmented fashion in order to maximize the reimbursement for various tests or procedures that are required to be billed together at a reduced cost. For example, clinical laboratory tests may be ordered individually, or in a “panel” (i.e., a lipid panel, an arthritis panel, a hepatitis panel). Billing tests within each panel as though they were done individually on subsequent days constitutes unbundling.

Excessive Services: These schemes typically involve the provision of medical services or items that are in excess of the patient’s actual needs. For instance, a medical supply company may deliver and bill for 30 wound care kits per week for a nursing home patient who only requires a change of dressings once per day.

Medically Unnecessary Services: A service is potentially fraudulent if it is not justified by the patient’s medical condition or diagnosis. For example, a claim for payment for an electrocardiogram test may be fraudulent if the patient has no symptoms that would necessitate the test.

Kickbacks: A health care provider or other person engages in an illegal kickback scheme when he or she offers, solicits, pays, or accepts money, or something of value, in exchange for the referral of a patient for health care services that may be paid for by Medicare or Medicaid. For example, a laboratory owner and doctor each violate the Anti-Kickback Statute when the laboratory owner pays the doctor $50 for each Medicare patient a doctor sends to the laboratory for testing.

If you or someone you love has fallen victim to medical fraud, don’t hesitate to contact a San Diego personal injury attorney at the Law Offices of Robert Vaage for a free consultation.