Health Care Fraud

Health care fraud is a crime that is committed when a provider or consumer submits, or causes someone to submit, false information for use in determining the amount of health care benefits payable.

Examples of health care fraud are:
1. billing for services not actually performed;
2. unbundling—-billing each stage of a procedure as if it were a separate procedure;
3. upcoding—billing for a more costly service than the one actually performed;
4. misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery;
5. falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary;
6. accepting kickbacks for patient referrals;
7. waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan;
8. billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

Help avoid health care fraud:
1. Ask questions about the services you receive, such as: Why are they needed and what is the cost?
2. Question advertisements or promotions that offer free tests, treatment or services
3. Fill out, sign and date one claim form at a time.