Question

Of the following practices, which constitutes fraud?

• Billing for services not provided

• Billing for services not covered under a patient’s health insurance

• Unbundling; that is, billing separately for each stage of a procedure

• A licensed health care practitioner allows an unlicensed person to bill an insurer under his name

• A medical facility waives deductible and copayment.

30 Are all of these practices illegal ? Are all of these practice unethical?

Answer 1

Yes these practices are illegal

The majority of health care fraud is committed by a small number of dishonest health care providers, and in some particularly distressing cases, by individuals only posing as legitimate health care providers. Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society

1.Billing for services not provided:  by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding otherwise legitimate claims with charges for procedures or services that did not take place.

2. 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

3.Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments—this is 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.

4.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 "financial hardship