How to Identify and Expose Healthcare Fraud

Health care fraud not only increases the overall cost of healthcare, but it’s also a crime. It happens when a dishonest health care provider or consumer intentionally submits, or has someone else submit, false or misleading information to pay for health care benefits. This often happens through a government program such as Medicare or Medicaid. This kind of fraud is widespread and can be brought under control only when those who know about it report it to authorities.

How healthcare fraud takes place

These are some examples of healthcare fraud by providers:

• Billing for services, supplies or medical devices not actually performed or supplied
• Falsifying a diagnosis to justify tests, treatments or procedures that aren't medically necessary
• Providing false information about a procedure, stating it’s something that will be paid for when what was actually done wouldn’t be paid for
• Upcoding or billing for a more expensive service than what was actually performed
• Unbundling or billing each stage of a procedure as separate, resulting in higher payment
• Accepting kickbacks for referring patients
• Waiving patient co-pays or deductibles and then over-billing the insurance carrier
• Billing a patient for more than the co-pay amount for services though they were prepaid or paid in full under the terms of a managed care contract.

Indications your employer may be engaged in healthcare fraud

If you’re a healthcare professional or work for one and you suspect healthcare fraud is taking place, here are things to look out for:

• Do patients legitimately have medical problems or do they just seem to come to the office for some other reason? Might these people be obtaining some kind of compensation by the practice, so their medical information can be used? Does the practice appear to be a “pill mill” where insurers and government programs are being used to feed addictions?
• Do medical records appear to be falsified? Do services, medications and medical devices appear in records but they haven’t actually been provided? Did a patient receive one treatment but another, more expensive one is in the medical chart?
• Do there seem to be too few patients, given the revenue coming into the office? Might claims for patients who don’t actually exist be filed in order to keep money flowing into the practice? Do those running the practice appear to be living beyond their means?
• Are patients being advised to undergo treatments they don’t need? Are they being told that tests show they have a serious medical condition while the actual results are the opposite?
• Does the physician in charge of the practice appear to have serious financial or personal problems that may need more income than he or she is getting through the practice? Does the person have a substance abuse or gambling addiction that may require more money than patients would genuinely provide?
• Are insurers being billed for work done by nurses, but the practice claims doctors performed it?
• Is the practice referring patients to outside services like physical therapy though it’s not needed?
• Are outsiders being paid to refer patients to your practice?

What you should do if you want to report healthcare fraud

If you find yourself in this situation, you have some options if you want to disclose healthcare fraud to the right people so those guilty of it can be held accountable.

You should contact an attorney who handles healthcare fraud whistleblower cases. The law can be complex, and you need to balance reporting wrongdoing while protecting your own interests. You may disclose what you know internally, to your state’s insurance department or to Medicare or Medicaid if they’re being defrauded. You need to discuss with an attorney who you should disclose to, when and how.

You could gather evidence of the fraud in a way that won’t get you fired, if at all possible. Write down ...

• What you see and know
• The names of those perpetrating the fraud and those witnessing it
• Quotes from those you work with about fraudulent practices.

Your use of a practice’s computer may be tracked. If you email incriminating evidence to your personal email, your employer will be able to see your use of the practice email account and the computer. Even printing of documents to bring them home could be traced back to your computer. There are also privacy laws you need to follow. Revealing personally identifiable information about patients may be used as an excuse by your employer to fire you.

If after you report healthcare fraud to your employer or your employer learns you’ve informed an outside agency or insurance company and you’re fired in retaliation, you may have grounds to file a legal action against the practice. If Medicare or Medicaid is being defrauded, you may be able to file a lawsuit on behalf of taxpayers to recoup the money that’s been defrauded, and you may be able to obtain a share of what’s collected from the practice.

Healthcare fraud is bleeding our system dry, and we need people to stand up when they know it’s going on. If you know of such fraud and report it, you may benefit from state and federal laws that will protect you and potentially reward you for your efforts.