Health care fraud is a big problem in the United States. According to the National Health Care Anti-Fraud Association, health care fraud costs the country billions of dollars every year.
There are many different types of health care fraud, but some of the most common include billing for services that were never rendered, billing for more expensive services than were actually provided, and submitting false or inflated claims to insurance companies.
If you’re accused of health care fraud, it’s important to know your rights and to understand the investigation process. This blog post will cover some of the basics of health care fraud investigations, including common red flags that investigators look for and who generally reports suspicious activity.
Common Red Flags That Investigators Look For
There are certain red flags that investigators often look for when trying to prove health care fraud. Some of these red flags include:
Unusually high numbers of patient visits or procedures performed
The high numbers of patient visits or procedures performed could be a sign of health care fraud if there is no logical explanation for the increase. For example, if a clinic suddenly has twice as many patients as usual, it may be a sign that the clinic is billing for services that were not actually provided. Similarly, if a doctor performs an unusually high number of procedures, it may be a sign that the doctor is billing for procedures that were not actually performed.
A large number of patients who live far away from the health care provider
The lion’s share of a healthcare clinic’s business, for example, comes from a 20-50-mile radius. While specialty hospitals such as MD Anderson could see patients from all across the country, it’s quite unusual for the average facility. As such, large numbers of patients coming from far distances can ring the alarm bells.
Billing for services that were never rendered
This can happen in a number of ways, but one of the most common is when a provider bills for a higher level of service than was actually provided. For example, a provider may bill for a consultation when only a brief exam was conducted.
In other cases, providers may simply invent services that were never performed and bill the patient or insurance company for these nonexistent services.
Billing for more expensive services than were actually provided
Another riff on the previous section, a doctor or nurse practitioner itemizes a more advanced procedure than what the patient actually received. This can be a red flag for investigators, as it may indicate that the person is trying to overcharge the system. This type of behavior can lead to charges of health care fraud, as the individual is essentially trying to cheat the system in order to make a profit.
Submitting false or inflated claims to insurance companies
This can happen if a person exaggerated the cost of their medical treatment or submitted claims for services that were never actually received. In some cases, people have even been known to create fake medical bills in order to get the insurance company to pay out more money. Health care fraud is a serious crime that can result in heavy fines and significant jail time, so it’s important to be honest about all dealings with an insurer.
Who Generally Reports Suspicious Activity?
Suspicious activity in the healthcare industry is generally reported by employees, patients, and health care providers. However, anyone can report suspicious activity if they have reason to believe that fraud is occurring.
The important thing to remember, especially when dealing with billing matters and insurance companies, is that everyone is looking over your shoulder. Mistakes can have wide-reaching ramifications so make sure you get it right the first time and act in good faith.
Fight Health Care Fraud Accusations Head On
Health care fraud is a serious problem in the United States. If you’re accused of health care fraud, it’s important to know your rights and to understand the investigation process. This blog post has covered some of the basics of health care fraud investigations, including common red flags that investigators look for and who generally reports suspicious activity.
If you have any questions or concerns about a possible health care fraud investigation, please contact John Teakell today. He is an experienced defense attorney who can help protect your rights.
