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What is Health Care Fraud and How to Deal With It

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One of the things you may get yourself into is health care fraud. You may not know it right away, but it's essential to be keen. Hence, you must know what it is and its form so you won't be fooled into it.

What is Health Care Fraud?

As said by the FBI, health care fraud is the act of swindling private or government healthcare programs. These actions usually defraud health care providers, companies, or individuals.

Health care fraud occurs when a provider or a consumer purposely presents or persuades someone else to file fraudulent or misleading information utilized in determining the amount of health care benefits payable. It is a white-collar crime that comes in the form of filing of deceptive health care claims to make a profit.

Commonly, health care frauds may come in the form of:

  1. Fraudulent insurance cards offer
  2. Bogus health insurance marketplace assistance
  3. Stolen health information, medications, supplements, weight loss products, or pill mill practices.

Categories of Health Care Fraud

There are two categorizations of health care fraud: the provider health care fraud, and consumer health care fraud.

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Examples of provider health care fraud include:

  • If the health care provider billed you for unperformed services.
  • If a medical practitioner falsifies a patient's diagnostic results, or do such acts to prove tests for surgeries or other procedures even if it's not needed in the medical aspect.
  • If they falsified procedures that they performed to get payment for the services that are actually not performed.
  • Upcoding - They billed you for a more expensive service than what they performed.
  • Unbundling - They charged you for every stage of a procedure, even if it's not supposed to be a separate procedure.
  • If the practitioner takes bribes for patient referrals.
  • Rejecting patient co-pays or deductibles and billing the insurance carrier extensively.
  • Charging the patient more than the co-pay amount even if the benefit plan through a managed care contract already settled the bills in prepaid or in full.

Meanwhile, examples of consumer health care fraud include:

  • A person files for claims for unreceived services or medications.
  • A patient is falsifying or modifying bills or receipts.
  • A person is asking someone's coverage or insurance card for personal use.

How to Avoid Health Care Fraud

Anyone can fall victim to healthcare fraud, but you can take certain precautions:

  • Do not sign unfilled insurance claim forms.
  • Never issue your medical provider a blanket authorization to charge for services rendered. (Blanket authorization is a formal, written consent endorsed to an individual to carry on with activity that doesn't need additional approval.)
  • Be informed of the expected charges from your medical providers.
  • Get acquainted with your insurer and provider and try to understand the benefits statement.
  • Never engage with door-to-door or telephone salespeople who promise free medical services or equipment.
  • The only people whom you can entrust your insurance/medicare identification are the practitioners who already provided you with medical services.
  • Have a detailed record of all your health care appointments.
  • Be knowledgeable when your doctor ordered medical equipment for you.
  • Do not get yourself fooled by spam email, internet advertisements, links in forums or social media, and questionable websites. Before clicking on any link, be sure to watch out for these red flags.

Now that you’re aware of what healthcare fraud is, the most important thing to do next is to keep constant vigilance. If you become a victim of healthcare fraud and need help, you can visit www.healthcarefraudgroup.com to learn more about what you can do to protect yourself. The website also allows you to hire a specialist from their pool of experts to guide you every step of the way.

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