Health care fraud and abuse is a national problem, that takes many forms, and affects all of us either directly or indirectly.
It is the deliberate falsification, dishonesty, or planned act of deception for the purpose of getting higher reimbursements.
Health care fraud costs the country tens of billions of dollars a year. Some patients are also harmed in furtherance of these schemes.
Some common types of fraud include:
- Allowing untrained or uncertified subordinates to provide medical treatments
- Billing for covered services when actual services provided were not covered
- Billing for equipment and products not ordered or distributed
- Billing for services not provided
- Carrying out unnecessary teeth removals on adults and children
- Charging for a more intricate service than what was provided
- Duplicate submission of claims for the same service
- Misrepresentation of provided services
- Ordering unnecessary lab tests
- Adding someone who is not eligible for coverage to a policy
- Failing to remove someone who is no longer eligible from a policy
- Using a member ID card that does not belong to that person
- Visiting several doctors to obtain multiple prescriptions
One of the most effective ways Legal Nurse Consultants determine if insurance information is being used deceptively, is to review the explanation of benefits forms sent to patients from their insurance company.
These forms list the services and supplies supposedly provided to patients from medical providers. If any billings are suspect, we will immediately contact the insurance company.
Our nursing knowledge, clinical experience & integrity are invaluable assets for your team & your cases…
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