Types Of Health Care Fraud
Health Insurance and Medical Billing
Health insurance and medical billing fraud occurs when a health care provider or individual deceives an insurer in order to receive greater reimbursement.
Examples of health insurance and medical billing fraud are:
- Billing for services not actually performed
- Upcoding, or billing for a more expensive service than the one actually performed
- Unbundling, or billing each stage of a procedure as if it were a separate procedure
- Falsifying a patient’s diagnosis to justify procedures that aren’t medically necessary
- Accepting kickbacks for patient referrals
- Waiving patient co-pays or deductibles and over-billing the insurance carrier
Medicare and Medicaid Fraud
Medicare and Medicaid fraud is medical billing fraud specific to these government benefit programs. It is when a health care provider claims Medicare or Medicaid health care reimbursements that they are not entitled to in order to dishonestly collect money.
File a Medicaid Fraud Complaint
The Attorney Generals Medicaid Fraud Control Unit investigates allegations of Medicaid fraud. To file a Medicaid complaint, contact the Austin headquarters.
- Mail: Medicaid Fraud Control Unit at the Office of the Attorney General, P.O. Box 12307, Austin, TX 78711-2307
Home Health Care Fraud
Home health care fraud is when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered.
Drug Fraud and Abuse
Billing For Services And/or Supplies Not Provided
This is one of the most common forms of Medicaid fraud. Fraudulent providers sometimes file a request for payment for services or supplies they did not provide. An example would be a doctor billing for 2 hours of exam time when only 1 hour was provided. Another example is a transport company billing for extra miles to inflate the cost of a trip.
How To Spot Medicaid Fraud
Medicaid recipients, or their family members and people who work for them, should closely monitor medical billing statements. Keep a lookout for unusual activity, such as:
- charges for services that were never performed, or for goods you never received.
- billing for the same thing twice.
- services that were not ordered by your doctor.
- providers who recommend/perform unnecessary services or tests.
Medicaid fraud may also include:
- a patient whose medication is missing.
- unexplained cuts, black eyes, bruises or burns.
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Physical Abuse Of A Patient
When any provider or employee of a Medicaid-funded facility physically assaults any resident, MID can investigate. We investigate abuse whether or not it leads to serious injury, and even if the patient is not a Medicaid recipient. We also investigate physical abuse of Medicaid patients by caregivers in settings other than nursing homes.
National Report Medicare Fraud Day Official Website
The official National Report Medicare Fraud Day is September 12. This website also show you how to report all types of Medicare fraud, ranging from Home Health Care Fraud, Kickback Fraud, Long Term Acute Care Hospital Fraud, Medicare Advantage Fraud, Stark Violations Fraud, and Upcoding Fraud. Each of these types of Medicare fraud has their own National Day too! Explore this website and find out how to detect and then report Medicare fraud.
Ten percent of all Medicare funds are lost due to fraud. Because the government spends $650 billion a year on Medicare $65 billion a year is lost to Medicare fraud. Its no wonder why we have a national health care crisis!
The money stolen by those cheating Medicare comes out of your pocket, as a faithful citizen and taxpayer. Worse yet, for every dollar lost to Medicare fraud is one less dollar available for our elderly or disadvantaged citizens needing health care. Are you willing to put up with that or do you want to do something about it?
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Suspected Fraud Against Activities Funded By The Department Of Health And Aged Care
Activities funded by the Department of Health and Aged Care may include:
- aged care services
The Department also funds activities through grants and other payments.
Fraud against these activities may include:
- providing misleading information to receive a grant or payment
- using Health and Aged Care funding for different purposes than it was meant for
Anyone can report suspected fraud against activities funded by the Department of Health and Aged Care. Any information that you can provide is valuable.
What Are The Rewards For Reporting Medicare Fraud
Reporting Medicare fraud does offer up to a $1000 reward to eligible claims. Five conditions are necessary for a reward to be paid.
FCA Claim Bounties:
The reward is based on a percentage of 10% of the recovered sum up to a maximum of $1,000. Whichever amount is less. If more than one person is eligible for a reward it is split between them.
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How To Submit A Tip
You dont have to give us your details when you submit a tip-off.
But it helps if you do, so we can contact you for more information if we need it.
If you want to make a report, use our tip-off form.
Or, if you cant use the webform, call our hotline:
Provider Benefits Integrity Hotline
If you have concerns relating to a health provider you can submit details to the department online by completing the tip-off form or by calling the dedicated hotline between the hours of 9am to 5pm AEST.
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Two Ways To Report Medicare Fraud
There are two ways to report Medicare fraud. They are drastically different, with different ways of reporting and different results.
The first method is to report Medicare fraud under the U.S. Department of Justice whistleblower reward program, which pays significant rewards. The average is $690,000.
The second is to report fraud directly to the Centers for Medicare & Medicaid Services , which oversees the Medicare and Medicaid programs. Although CMS does not pay significant rewards, it is easy and can be done anonymously.
This official national report Medicare fraud day website provides you with the tools to report Medicare fraud to DOJ for a reward or directly to CMS. See the links below.
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What You Should Know:
Medicare fraud occurs when a practitioner knowingly bills the Medicare system for products or services that were not used by the beneficiary, is involved in reward schemes for such products or services or makes illegal referrals for designated health services. To combat fraud and abuse, its important to know what Medicare fraud looks like, how to protect yourself and how to report Medicare fraud.
If You See A Name You Dont Know On Your Medicare Statement
Most of us recognise our doctors name, so its not unusual to be concerned if you see a name you dont recognise on your Medicare statement.
If this happens, consider whether you might have had a service, such as an eye test, pathology, or diagnostic imaging, from someone other than your usual provider.
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How To Report Fraud
You can help protect your tax dollars by reporting suspected fraud by phone, through the Internet or by regular mail. You can do this without giving your name, but if you agree to give your name and other contact information, that helps the investigators to obtain future information.
Before you make a report, try to get as much information as possible, including:
- the name of the person you suspect of committing fraud. This might be a person receiving medical benefits or a health care professional hospital, nursing home, or other facility that provides Medicaid services
- the Medicaid ID number
- the amount of money involved, and/or
- a description of the acts that you suspect involve fraud
What Can You Do To Help Prevent Report And Stop Fraud Waste And Abuse
Report potential fraud:
- Fraud and Abuse Hotline: 1-866-685-8664
- Arizona Complete Health Attn: Compliance Officer1870 W. Rio Salado Parkway Tempe, AZ 85281
- Mail: Office of Inspector General 801 E. Jefferson St.,
- Outside of Maricopa County: 888-ITS-NOT-OK or 1-888-487-6686
In addition to notifying the regulators above, providers must immediately notify Arizona Complete Health of all suspected fraud, waste, and/or program abuse. Arizona Complete Health providers must report suspected fraud, waste, and program abuse directly to the health plan immediately upon identification and notification to their regulator.
To protect the public from consumer fraud.
If you believe you have been the victim of consumer fraud, you may file a consumer complaint with the Arizona Attorney Generals Office. For consumer inquiries, or to request a complaint form, call 542-5763 , 628-6648 , or toll-free outside of metro Phoenix, 352-8431.
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How Do They Do It
Some medical professionals billed for services they didn’t do, such as billing dead people and falsifying patient records to increase their incomes.
When a health practitioner bulk bills for a service they send your bill directly to Medicare, making it free for you.
But if a doctor illegally bulk bills for a service you didn’t get, they will be receiving money from Medicare that they aren’t supposed to.
Documents obtained by the Herald, The Age and 7.30 as part of the investigation show an online telehealth company appears to have illegally bulk-billed patients while also charging $38 or $50 a visit.
Avoid And Report Medicare Fraud And Abuse
Medicare fraud can put your health at risk. Find out how to identify and report suspected fraud and abuse.
Medicare consultant and expert, seniors advocate, and author
Medicare fraud is a serious issue that can cost taxpayers billions of dollars and put beneficiaries health at risk. In 2019 alone, there were almost $29 billion of improper payments for Medicare Private Fee-for-Services , representing 7.25% of all payments, according to the Centers for Medicare & Medicaid . While most Medicare providers are ethical individuals who try to provide high-quality care, avoiding and reporting Medicare fraud and abuse is everyones responsibility.
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How Do You Report Medicare Fraud Or Abuses
Are you wondering how to report Medicare fraud? You can report Medicare fraud or suspected fraud in several ways:
- Contact Medicare at 1-800-MEDICARE
- Contact the Department of Health and Human Services Office of Inspector General at 1-800-HHS-TIPS
- File a complaint online with the OIG to report any potential fraud, waste, and abuse
- Contact the Senior Medicare Patrol for more help at 1-877-808-2468
To report fraud, youll need:
- Your Medicare number
- Your providers name and information
- Details about the fraudulent service
- The payment paid by Medicare
- The date of the service
If you notice something unusual on your MSN, report the Medicare fraud or abuse as soon as possible.
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How To Report Medicare Fraud Anonymously
Medicare fraud costs US taxpayers approximately $60 billion a year in the form of abuse, fraud, and waste. Thats money that goes to unethical and dishonest medical care providers and comes straight out of the pockets of taxpayers hard-earned paychecks. Furthemore, the patients who depend on the medical services are swindled out of getting the services they need as resources are diverted by greedy, unscrupulous parties looking to cash in at the expense of others.
If you are a doctor, nurse, pharmacist, or employee of a medical provider or insurance company, you may well have seen Medicare fraud practices up close, carried out by co-workers, administrators, superiors and so on. For those who have the courage and loyalty to their fellow citizens, there are ways to report Medicare fraud to prevent injustice from occurring, and you may even report Medicare fraud anonymously. In addition, monetary rewards may be available to you in return for reporting Medicare fraud.
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What To Expect After Submitting Your Complaint
An OIG analyst will review your complaint for relevance and completeness. Not all complaints result in an investigation.
If you have identified yourself, a reviewing official may contact you for further information. However, if you are not contacted it does not mean your complaint is not being investigated.
What To Report To Us
Let us know if you think someone has charged for a medical service or medicine you didnt receive.
We accept tip-offs about:
- doctors, pharmacists, dentists and allied health professionals such as physiotherapists
- pharmacies, medical practices, hospitals and administrative staff.
The kinds of payment concerns to report to us include:
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What You Need For Report Public Benefit Fraud To The Office Of The State Auditor
The Office of State Auditor Suzanne M. Bump’s Bureau of Special Investigations uses tips from the public to identify potential fraud in our public benefit programs.
Using the methods below, please provide as many details as possible about the alleged public benefit fraud, including:
- the name and address of the individual suspected of committing the fraud
- any potential aliases of the individual suspected of committing fraud
- the details of the suspected fraud
- your relationship with the individual suspected of committing the fraud and
- any additional information that may help our investigators.
All information is accepted in confidence, and promptly reviewed upon receipt.
Please note, in order to maintain the integrity of our investigations, we are unable to provide updates on ongoing or potential investigations that result from tips we receive.
Commingling Of Patient And Facility Funds
If a Medicaid-funded facility willfully deposits a residents funds into the facilitys operating account for use by the facility, the money is commingled, and the residents funds are available to pay the facilitys operating expenses rather than to benefit the resident. We investigate the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.
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How Confidential Is A Medicare Fca Claim
When an FCA Claim is filed it is sealed by the U.S. Circuit Court. The Whistleblowers identity will remain anonymous as the Government investigates the validity of the claimants accusations. This should only take 60 days but could take longer if the Government needs more time.
“You can discuss the situation with your qui tam attorney confidentially who will help ensure YOU are protected…”
The U.S. Attorneys Office will complete their review of the case and decide whether or not to assist in the prosecution of the case. If they decide to assist, the whistleblowers reward will be reduced to 15%-25% of the total recovery – but the weight and resources of the government are brought into the investigation. If the Government decides against further action, plaintiffs can still proceed on their own.
The whistleblower reward from a stand alone action is 25%-30% of the recovered sum.
Remaining an anonymous whistleblower may not be possible once the case is unsealed and made public. However, the False Claims Act provides protection to people who blow the whistle on healthcare fraud via the Department of Labor and the Department of Justice.
At any point in the FCA process legal counsel can be retained. Finding a qui tam lawyer with experience in healthcare fraud and FCA claims is recommended. Lawyers will consult on these type of cases for free and work on a contingency basis pending the strength of the case.
What Documents Do I Need To Report Medicare Fraud
If youre reporting Medicare fraud, its helpful to have some of your information ready.
- Medicare number
- Information about the service that was supposedly provided
- and the reason you think fraud was committed
If a reported Medicare fraud leads to the recovery of funds, Medicare may provide a reward. If you or someone you know suspects fraud, waste, or abuse, report it immediately.
The Center for Medicare and Medicaid Services states that Medicare fraud is:
- Intentionally billing Medicare for a service not provided
- Billing Medicare at a higher rate
- If a provider pays for referrals of Medicare beneficiaries
Medicare fraud is severe its not human error, its highly illegal, and it involves doctors or beneficiaries abusing the system for their own benefit. Report Medicare fraud as soon as possible.
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Learn How To Recognize Report And Protect Yourself From Health Care Fraud And Abuse
Health care fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit. These schemes cost the nation billions of dollars each year and result in higher health insurance premiums and out-of-pocket expenses for consumers.
Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.
Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.
These practices can take many forms, the most common including:
The Consumer Protection Division of the Office of the Attorney General aims to help educate consumers on how to recognize fraud and abuse and how to file a complaint with the appropriate agency.
