Health Care Fraud
Total U. S. Healthcare Spending
Health Care in the United States has become a trillion dollar a year industry. This means that over $100 billion a year goes to fraudulent activity. This is part of the reason for a steep increase in the cost of your insurance.
How Much Fraud
Agencies that track statistics put the cost of healthcare fraud at anywhere from 3% - 15%, with 10% being the most accepted figure.
- 3-10% National Health Care Anti-Fraud Association
- 10% General Accounting Office
- 10% The Congressional Budget Office
- 15% The U.S. Chamber of Commerce
Health Care Reform
Public Law 104-191
In August of 1997 the Health Insurance Portability and Accountability Act (HIPPA) was signed into law. Part of this reform legislation was to reduce the amount of healthcare fraud.
HIPPA routed funds and resources to both Health and Human Services (Medicare) and Department of Justice to help combat fraud.
The Department of Justice Has Made it a National Priority
* Health Care Fraud had previously been #11
How Does Federal Government get Involved in Health Care Fraud?
- Our office is responsible for investigating and prosecuting all fraud perpetrated on Medicare, Medicaid, Tri-Care, and other government funded services.
- Cases can be prosecuted either in a Federal Criminal Court, or they can be sometimes handled by the Federal Civil Courts
What is Fraud & Abuse?
Fraud - Willfully and Knowingly act with the Intent to obtain something of Value
Abuse - Obtain Something of Value by Furnishing Incorrect or Misleading Information
Examples of Fraud & Abuse
- Falsifying diagnoses to get a non-covered service paid. Example - Billing smoking cessation as psychotherapy
- Upcoding, - charging for a more expensive procedure than the one that was performed. Example - billing an allergy injection as a high level complex office visit.
- Double Billing, or billing twice for the same service. Example – Doctor A and Doctor B bill for the same office visit
- Billing for Unlicensed Providers. Example – a non certified massage therapist performs services that are billed as if the doctor did them
- Waiving Copays or Deductibles
Who is Involved in Fraud & Abuse?
Health Care Providers
- Doctors, Physical Therapist, Psychologist, Podiatrist – to name a few
- Hospitals, Nursing Homes, Assisted Living Centers
- Durable Medical Equipment suppliers
- Pharmacy/Pharmacist
Insurance Companies.
If You Suspect Fraud
- Contact your insurance carrier they can usually clear up simple misunderstandings
- Contact Health & Human Services and/or the Federal Bureau of Investigation