Health Care Fraud

Tuesday September 6, 2011

To be posted on Google.com

http://googleblog.blogspot.com/LinoDial


Title : Health Care Fraud

By : Dr. Lino Dial


Sources : Health Care Fraud from : Cornell University Law School ,

Fraud magazine and Southern California lawsuit for Health Care Fraud.


I From Cornell University Law School , Legal Information Institute.

Health Care Definition of the Day :

Highlights :

Types of Fraud include :

1. Kickbacks.

2. Billing for services not rendered.

3. Billing for unnecessary equipment.

4. Billing for services performed by a lesser qualified person.


Health Care Providers who commit these fraud :

1. Hospitals.

2. Home Health Care.

3. Ambulance Services.

4. Doctors.

5. Chiropractors.

6. Psychiatric Hospitals.

7. Laboratories.

8. Pharmacies.

9. Nursing homes.


Violators may be prosecuted under 18 USC 1347.


II Sources : Fraud Resources , Fraud Magazine , National Anti - Fraud

Director of Blue Cross Blue shield Association.


Published few years ago in Fraud Magazine.

Highlights :

1. Working definition of Health Care Fraud :

The intentional misrepresentation of material ( important ) fact submitted

on or in support of a claim...

Theft of money or property.

2. Health Care Fraud has been with us for a long time. Fraud is driven by a

basic human weakness. We are all tempted by greed and we all are intrigued

by the idea of getting something for nothing.


Common types of Health Care Fraud :

1. Phantom billing, adding charges for services not performed.

2. Upcoding : charging for more expensive service code.

3. Doctor shopping : getting prescriptions from ten different doctors.

4. Providing unnecessary tests , procedures , surgeries , etc.

5. Misrepresenting services.

6. Masquerading as Health Care Providers : impostors.


III In 2005 Blue Cross Blue Shield filed lawsuit against Southern Calif :

9 --- Outpatient surgery clinics.

7 --- Medical management companies

34 -- Individuals

For massive " rent - a - patient " schemes.

Summary ( brief description of the fraud ) :

The scheme was carried out using paid recruiters to enlist patients

nationwide to travel to the California - based Surgical Centers and undergo

needless and hazardous diagnostic surgical procedures.. The " patients "

received cash compensation or cosmetic surgery and providers submitted

and collected on inflated insurance claims.

The common procedures performed are :

1. Colonoscopies.

2. Endoscopies.

3. Septoplasties ( nasal surgeries ).

4. Gynecological operations : Laparostomies, D and Cs.


There are numerous cases of documented Health Care Fraud.


To be continued.