White collar crime is something that rarely receives as much attention as violent crime, but it is very common. In the medical industry, the most widely recognized crime would likely be fraud, although people could also misuse their access to prescription medications or patients.
Despite what the media might make you think by their focus on people getting benefits they don’t receive, the most common forms of health insurance fraud actually stem from provider behaviors. If you work in health care, being able to recognize some of the most common forms of health insurance fraud could help you avoid accidentally committing them.
Billing for care that a patient did not receive
Doctors or practice managers might bill insurance companies for appointments that never happened or add treatments and procedures to the insurance bill for a patient who did not receive them.
Changing the billing code to a more expensive procedure
There are often numerous different treatments or procedures that a doctor could perform on a patient. They usually select the one that will be the most effective and least intrusive. However, they may choose to bill for a more involved or expensive procedure in the hope of maximizing their reimbursement for their work.
Unbundling or separating a procedure in to multiple procedures
When a health care provider or practice agrees to participate with a specific insurance plan, they generally agree to certain compensation rates. Bundled services that offer a discount for treatments often provided in conjunction with one another are a common part of the insurance contract between a provider and an insurer. Separating discounted procedures out in to individual billing codes might mean that the company can request more compensation, but it is also a form of fraud.
Those who work in health care, especially in billing departments, will want to keep themselves aware of trends and insurance fraud to protect themselves from unwittingly committing a white collar criminal offense.