Most healthcare providers and physicians in Texas are honest. There are a number of ways certain members of the health care profession try to enrich themselves by committing fraud with the Medicare system. An investigator will work hard to try and determine if actual fraud occurred or an honest mistake.
Fraud Or Mistake
In order for a healthcare provider to commit fraud, they have to knowingly participate in a plan or scheme to initiate falsehoods as a way to obtain a certain level of financial benefit. Committing fraud does not involve people having a bad day and putting down a patient as receiving treatment when they missed an appointment. Fraud is an intentional act. This is when a healthcare provider intentionally bills for treatments and procedures they did not provide and more. Committing fraud is done knowingly for a financial benefit.
Billing For Services Not Provided
It is not uncommon for a healthcare provider to submit claim forms for services or care that was not provided. This can often be the result of poor patient file documentation. This can appear to be fraud if a pattern of such deception is discovered. An investigator will look at the claim form, and for proof, a client was actually at the healthcare provider’s on specific dates and more. They often talk to patients who will remember when they got a specific procedure.
Waving Co-Payment or Deductible
Medicare providers are not permitted to wave their patient’s co-payments or deductibles. There are some healthcare providers who will do this and then submit false documentation to make up the difference. Some have said they were trying to help out their patients who were struggling financially. This doesn’t matter. An investigator will end up asking patients for copies of a receipt, canceled check or credit card receipt to show their co-payment and deductible was paid.
Misrepresenting Who Provided Service
Many times investigators will find that a medical doctor has signed a form showing they are the ones who provided a particular service. After an investigation, it is discovered a lesser-educated medical professional actually performed the treatment. In most cases, the healthcare provider would have been paid for the services performed by the other person, but at a lower rate.
Billing A Service Not Covered As A Covered Service
There have been situations where a healthcare provider has gotten paid for treatments not covered by Medicare. It these situations, the treatment can be given a code and called something that is isn’t. Many healthcare providers do this and believe they are helping their patients. It is also possible for this to happen when someone doesn’t completely understand the proper coding as well as the description for a service.
This often involves a healthcare provider submitting for payment for services that aren’t really medically necessary. This is often done by some providers who use it with their hypochondriac patients. They will provide as many tests and exams as possible until the patient’s coverage no longer makes payments.
Date Of Service Misrepresentation
This happens with healthcare providers claim to provide treatments on two separate days rather than just one. An office visit is treated as a separate billable service. The services listed on the claim form are provided, but the dates are not accurate. The goal is to get paid twice for one patient visit.
Incorrectly Reporting Procedures Or Diagnoses
This involves a healthcare provider billing for extra services when they falsely report a serious diagnoses or treatment provided. This could happen when a patients falls and goes to a healthcare provider for a simple examination. The healthcare provider makes an intentional misdiagnose. They claim the person has head trauma and requests blood tests, CT scan or MRI and more. During this time, a patient’s condition is not being treated the way an honest healthcare provider would handle it.
Federal law makes it possible for a dishonest Medicare provider to receive both criminal and civil punishments should they be found guilty of fraud. Criminal punishments could involve fines, payment of restitution as well as possible prison time and probation. Civil punishments could involve paying the victim for any of losses they experienced as a result of fraudulent care. Prison time, if found guilty, could be as long as ten years for each offense. Fines can be up to $500,000 for each offense. Restitution can involve paying back all money obtained fraudulently. Probation can last up to three years.