The majority of
health care fraud is committed by organized crime groups and a very small
minority of dishonest health care providers. The most common types of health
care fraud include:
- Billing for services that
were never rendered-either by using genuine patient information, sometimes
obtained through identity theft, to fabricate entire claims or by padding
claims with charges for procedures or services that did not take place.
- Billing for more expensive
services or procedures than were actually provided or performed, commonly
known as "upcoding"-i.e., falsely billing for a higher-priced
treatment than was actually provided (which often requires the
accompanying "inflation" of the patient's diagnosis code to a
more serious condition consistent with the false procedure code).
- Performing medically
unnecessary services solely for the purpose of generating insurance
- Misrepresenting non-covered
treatments as medically necessary covered treatments for purposes of
obtaining insurance payments-widely seen in cosmetic-surgery schemes, in
which non-covered cosmetic procedures such as "nose jobs" are
billed to patients' insurers as deviated-septum repairs.
- Falsifying a patient's
diagnosis to justify tests, surgeries or other procedures that aren't
- Unbundling - billing each
step of a procedure as if it were a separate procedure.
- 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.
- Accepting kickbacks for
- Waiving patient co-pays or
deductibles for medical or dental care and over-billing the insurance
carrier or benefit plan (insurers often set the policy with regard to the
waiver of co-pays through its provider contracting process; while, under Medicare,
routinely waiving co-pays is prohibited and may only be waived due to