A fraud examiner dissects health care fraud schemes

The constantly evolving U.S. healthcare system imposes a variety of challenges on Michigan providers. Frequent changes to compensation models and billing regulations can result in billing errors that sometimes result in uncollected revenue and sometimes result in insurer overpayments and investigations of possible healthcare fraud.

The Association of Certified Fraud Examiners (ACFE) has on its website a list of health care provider fraud schemes compiled by veteran Certified fraud examiner and private investigator Charles Piper.

Billing for services not rendered

Certified fraud examiner and private investigator Charles Piper says that in almost every healthcare fraud investigation he’s conducted, he has found evidence that the provider submitted claims to Medicare, Medicaid or an insurance company for care that was never provided and that patient files had no supporting documentation.

Billing for services not rendered, he says, is “real easy money.”

Piper says though he understands that records can be lost or misplaced, “a pattern of billing for services and care with no supporting documentation is unacceptable and unlikely to be coincidental.”

In addition to examining documentation, fraud investigators conduct interviews with staffers and patients listed in claims.

Misrepresenting the provider of care

While physician impersonation is pretty rare, this form of misrepresentation of the provider of service does happen. It’s much more common for misrepresentation to involve a physician signing off on insurance claims, though the care was provided by a staffer with less training.

Example: a patient goes to a mental health clinic to see a psychiatrist who can prescribe medication, but is instead directed to a social worker unqualified to provide the level of care sought. Regardless, the insurer is billed as if the patient had been seen by the psychiatrist.

Misrepresenting dates of service

Piper says providers can increase revenue by billing for two separate visits/treatments when the care took place on just one day.

Waiving deductibles and/or co-payments

Most government health care plans and private insurers don’t allow medical providers to waive patients’ co-payments or deductibles. However, unscrupulous providers have waived those fees and then padded their claims to make up the difference, apparently to ensure that a financially challenged patient won’t skip visits and treatments because of out-of-pocket expenses.

A possible remedy

Unfortunately, coding, accounting and billing errors can result in audits, investigations and sometimes criminal charges of healthcare fraud. In some circumstances, self-disclosure can resolve overpayment issues or other financial compliance matters.

A skilled healthcare law attorney can guide you through the self-disclosure process or help you with other compliance resolutions while protecting your rights and interests.