Fraud can affect any industry, from cybersecurity to home improvement. However, the insurance world experiences the most, and no other sector faces the most scams than does health care, reports the Coalition Against Insurance Fraud.
While many fraudulent activities are intentional, others may be accidental due to errors. Therefore, it is important to know what the top causes of health care fraud are so you can avoid mistakes that will lead to criminal charges and other consequences.
Some providers enter false information into medical records for purposes such as to justify unnecessary procedures or claim the work someone else did just to get the insurance money. Unfortunately, it is not enough to be honest on forms. Poor recordkeeping is one of the biggest reasons for errors in health care, so it imperative to regularly ensure records are accurate to avoid legal trouble of all kinds.
Another type of fraud occurs in billing, such as the following:
- Billing for a procedure the patient did not receive
- Billing for a covered procedure because insurance does not cover the actual one
- Billing for a more expensive procedure than the patient underwent (upcoding)
- Billing a procedure as individual steps (unbundling)
- Billing the patient more than the co-pay
Coding medical bills is no easy task anyway, so make sure you and your staff have proper training to prevent mistakes that will look like fraud.
Networking and community are important aspects of being a medical provider. However, when such turns into kickbacks and bribery for referrals, it enters dangerous territory. You may think that this type of fraud only applies if you exchange cash. However, even gifts, discounts and traded services count, so stay away from giving or receiving any type of reward for referrals.
Prescriptions can lead to all sorts of illegal activity, and not just from providers. Some are intentional: Doctors may write fake prescriptions for money, or pharmacy staff may submit false claims, steal the drugs and sell them. Others are not: Pharmacists may not check patient prescriptions to ensure they are real or supervise staff properly to prevent theft. With so many problems that can arise in a pharmacy, following best practices is a must to guarantee compliance.