What is Health Care Fraud?
A health care provider or consumer commits fraud when he or she deliberately breaks the rules
to get payment or treatment to which he or she is not entitled.
To illustrate, here are
examples of health care fraud sometimes committed by providers:
- Billing a health insurance company or government program for
services when he or she has not provided any – or billing for extra services or
procedures that were not provided.
- Billing a health insurance company or government program for
procedures or services that cost more than those actually provided.
- Performing procedures or services that the patient does not need
just so that the provider may bill an insurance company or government program. Sometimes unnecessary procedures or
services can harm patients.
- Rendering services that are not covered by the patients insurance
– and/or are not necessary – but submitting a bill for covered and medically
necessary services.
- Reporting a false diagnosis as the basis for tests or procedures
that the patient does not need.
- Billing separately for each step of a single procedure to increase
what is paid for the procedure.
- Accepting “kickbacks” for referring patients to other providers.
An individual commits health insurance fraud
by:
- Allowing someone else to use
his or her identity and insurance information to obtain health care
services.
- Using benefits to pay for
prescriptions that were not prescribed by his or
her doctor.