Ileana Hernandez of Manatt, Phelps & Phillips Law Firm is a member of the firm’s healthcare litigation practice. She talks about healthcare fraud in the U.S.
Hernandez said that there are three basic types of healthcare fraud in this country: billing for services not rendered, upcoding billing for more expensive services or procedures than were provided, and criminal referrals for services.
For the first type, Hernandez said that a typical example of this is a doctor billing for medical equipment or devices – such as crutches – that were not even given to the patient. In some cases, the patient will be billed for more expensive supplies than those used.
For “upcoding” offenses, Hernandez said providers to bill for more complex or expensive services or procedures than were actually provided. This is a more subtle form of fraud because the medical service or procedure was actually given; it’s just billed as something different.
By way of example, Hernandez said that a patient who has knee replacement surgery might be billed for equipment – such as special screws – that are not in fact used for that patient but are instead routinely available to the surgeon.
Lastly, she said that criminal referrals involve instances in which a patient is steered or “referred” by doctors or providers to particular physicians or facilities for care. The problem with these referrals is that they are often made by people who have an economic or other relationship with the referral source or by people who cannot provide objective, professional advice. As a result, these referrals can put patients at risk of receiving unnecessary procedures and services from unscrupulous providers.
In the aggregate, Hernandez said that fraud against Medicare and Medicaid accounts for over $60 billion in losses to taxpayers each year. Prosecutors are starting to pursue these cases aggressively, and Hernandez believes that this will continue.
“We’re likely to see more prosecutions, but also lawsuits by private insurers on behalf of their clients,” she said. “Healthcare fraud affects everyone.”
Hernandez added that passing healthcare reform will not mean the problem goes away. She said that healthcare fraud has existed for years, and it only gets more complex as new medical therapies develop.
“We will likely see more healthcare fraud as a result of the new laws and regulations, not less,” she said.
Hernandez said that tips for detecting Medicare and Medicaid fraud could be found at Medicare.gov, which has an area to report suspected instances of fraud. In addition, the site lists everyday items or services used by health care providers that are often billed improperly.
How to avoid becoming a victim of healthcare fraud:
- Be wary of doctors who encourage you to pay for procedures upfront and seek reimbursement from your insurer later; legitimate doctors will either accept the Medicare or insurance rate as payment in full or bill you separately for the difference.
- Check your Explanation of Benefits forms to see what was paid by Medicare or insurers, and compare that with how much you were billed. If there are significant discrepancies, you should report them to Medicare or your insurer.
- Ask for an itemized list of procedures performed on you before leaving the doctor’s office or hospital, and compare this list to the one you signed upon admittance; make sure these two lists are identical.