Healthcare Fraud FAQs

What Exactly is a Healthcare Fraud?

Medical fraud is a crime which involves intentional deception made by individuals or organizations to make illicit profits. There are various healthcare programs initiated by the government such as Medicare, Medicaid, TRICARE, etc., which cost the government billions of dollars every year. Healthcare frauds not only con honest taxpayers, but also risk the life of patients by recommending and administering unnecessary medical treatments and procedures.

How is Healthcare Fraud Different from Healthcare Abuse?

Every year fraudulent claims and healthcare programs cost the government billions of dollars. This can have an adverse effect on the country's economy and hence should be regularly kept in check. Often, people get confused about the difference between healthcare fraud and healthcare abuse. Here is the difference -

• Healthcare fraud is an intentional misinterpretation or deception of services, which are known to an individual or organization to be false and involves unauthorized issuing of reimbursements to a medical organization
• Healthcare abuses are the incidents or practices, which sway from the actual medical procedures and are different from the sound medical practice

What are the Common Instances of Medical Fraud?

Healthcare fraud cases are mostly complex, therefore, it is important to understand all the different types of frauds that occur in this industry. In general, healthcare fraud usually might involve any of the following -

• Billing a more expensive service or procedure, than that was actually provided to the patient, which is also known as up-coding
• Performing unnecessary procedures or providing unwanted services, solely for claiming insurance
• Claiming that the patient's diagnosis is false to justify all the tests, procedures or surgeries conducted, which were not medically necessary
• Accepting and giving kickbacks for any kind of patient referrals
• Billing for services or procedures that were never provided by using genuine identity of the patient, which is obtained through identity theft
• Waiving off any kind of patient deductibles or copayments and charging the insurance providers more than the actual bill or invoice

How to Detect Healthcare Frauds?

The process of medical fraud detection involves detective investigation and account auditing. Careful investigations reveal suspicious policy holders and fraudulent insurance programs. As auditing all the claims is not feasible, a more practical approach of short listing claims having suspicious activities and then auditing the same is often followed. There are also many analytical processes, which are often used to generate audit short lists. Besides, fraudulent claims often leave patterns over time, which can be easily detected using predictive models.

How Can a Healthcare Fraud be Prevented?

Numerous cases of medical fraud and abuse can be avoided by ensuring that all the patient information submitted is correct and the services or procedures carried out are merely in the interest of the patient. Before evaluating the patient health and during information submission, the following points must be kept in mind -

• Is the actual patient listed and whether the eligibility is verified
• Is the identity of the patient verified using photo identification
• Is the medical procedure recommended really necessary
• Are there accurate CPT and diagnostic codes
• Is the length of the session accurate and the session dates are correct
• Whether the services billed were actually performed

Avail Quick and Efficient Healthcare Services at Flatworld Solutions

Flatworld Solutions has been providing top quality healthcare services to global clients for over a decade now. Our 20 years of experience in the healthcare industry has helped us gain enough knowledge and understand all the intricacies associated with medical fraud. We know that every client is different and hence we not only provide services at reasonable rates but also customize them to precisely cater to the requirement of the client. This approach enables the clients to pay exactly for the services they avail.

As this is a critical field involving confidential information, we ensure total project security. We have the infrastructure and skilled resources to provide you with a range of healthcare services including medical billing and coding, medical transcription, healthcare claims adjudication, teleradiology services, healthcare software, medical animation and illustration, etc. In this way we help our clients in saving considerable time and cut down on unnecessary operational costs.

If you still have any questions which were not answered in the above FAQs on healthcare fraud, feel free to contact us.