Some Notes On Healthcare Fraud

This blog post is simple collection of notes and links to other resources on the topic of Federal healthcare fraud. You may contact us if you would like to schedule a consultation regarding any charges federal healthcare (or other related medical) fraud from around the United States.

Development of anti-fraud measures

The US Department of Health and Human Services (HHS) expressed concern about enforcement and investigations as a relates to healthcare fraud cases. That is why there have been new anti-fraud measures put in place in order to mitigate against healthcare fraud. As a general rule, healthcare fraud cases tend to be complex and difficult. Therefore prosecutions required slow and tedious work. However, times have changed.

Healthcare fraud investigations

As a general rule, those that pay and process high and high volume of claims have significant exposure. Understanding an insurance program as payment mechanisms and philosophy is an integral part of a fraud investigation.

Erosion of copayments

Copayment is a simple concept. It is the portion of the medical bill that the patient pays to the medical provider and in the case of Medicare it is usually about 20% of the bill. The notion behind healthcare payments is that in the world where major healthcare costs are paid by insurance and individual beneficiary will not seek unnecessary medical treatment if he or she has to pay a portion of those cares.

Defending healthcare fraud cases

It is often the case that schemes to defraud derive from the ingenuity of people that are able to manipulate the system in which a pair of health care services is different from the person actually receiving the services.

The majority of all healthcare fraud cases involve some sort of false billing and some sort of misrepresentation or lying on the claim form. As a general rule false billing is involved in each these cases. And it is clear that Medicare is by far the single largest p in the healthcare services industry. In most cases involving fraudulent billing as there are multiple victims including insurance payers, the government, and the insured.

False billing

At the core for false billing involves a lie about whether how when where and what service are items provided to the insured.

Medicare fraud and Medicare reimbursement defense

  • Medicare Part A deals with with hospital insurance benefits for the aged and disabled
  • Medicare Part B provides for supplementary medical insurance for the aged in the disabled
  • Medicare Part C is Medicare’s health maintenance organization or HMO insurance coverage
  • Medicare Part D involves Medicare prescription drug benefit coverage.