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9 Common Types of Healthcare Fraud in Texas

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From universal healthcare proposals to the ongoing opioid crisis, there are a lot of controversies swirling around the healthcare industry. One aspect that is brought up consistently is healthcare fraud.

This serious issue isn’t just a matter of conscience. It’s often considered criminal behavior, and it’s far from victimless. Healthcare crimes account for about three percent of our nation’s overall healthcare spending, and that $68 billion could be used to help citizens who are truly struggling with health issues.

Are you interested in learning what types of actions are committed that fall under the scope of healthcare crimes? Discover everything you need to know about the top nine types of health care fraud below.

1. Corruption and Getting Kickbacks

Have you ever been to a doctor’s office and noticed the plethora of pens, magnets, notepads and other items stamped with a pharmaceutical company’s name on it? These are usually offered to doctors as gifts. Doctors and healthcare providers have to be careful with this practice, though.

It’s illegal for healthcare providers to accept anything of value in exchange for favor about making a healthcare decision for a patient. In other words, a doctor can’t accept a kickback in exchange for prescribing a medication, using a specific type of medical device or to meet a quota.

That means all of those gifts from the pharmaceutical company can’t influence the doctor’s decision to prescribe their products to patients. Many doctors walk a very fine line when it comes to kickbacks, so every healthcare professional needs to be aware of the laws surrounding this issue.

Kickback can come in the form of gifts, vacations, money, or even referrals from other doctors.

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2. Allowing Nurses to Perform a Doctor’s Duties

It’s no surprise – a doctor’s services and time costs more than a nurse or other healthcare provider. Medicare, Medicaid, and other insurance providers have specific rules that state certain procedures must be executed by doctors only.

Sometimes, a healthcare clinic may attempt to cut costs by skirting around these rules.

The office may allow a nurse or another staff member to perform a procedure, but then bill the insurance company for the cost of the service as if the doctor performed it.

Not only does this type of healthcare fraud cause financial loss, but it also puts patients at risk. Undertrained nurses make more mistakes and could cause injuries or even death.

3. Providing Unnecessary Medical Services

If you were told you had cancer, then you’d do anything to extend your life, right?

Corrupt doctors know this, and they’re willing to use it against unsuspecting patients. This type of healthcare fraud happens when a doctor acts against a patient’s best interests in order to earn a profit.

Doctors commit this crime when they give you a false diagnosis or recommend an expensive procedure prior to exploring cheaper options first. A doctor may even perform a totally unnecessary procedure just to earn a profit.

4. Upcoding

Upcoding is a form of healthcare fraud similar to providing unnecessary services, but it involves required procedure that was performed. Here’s how it works:

  • The doctor provides care to a patient.
  • The doctor bills the patient for more complex or expensive services than actually provided.
  • The insurance company or patient pays more than they should.

When doctors bill you for services, they usually enter a code into their computer. That’s why this type of fraud is called upcoding.

Sometimes, this type of action is an honest mistake. Often, though, upcoding is a direct attempt to gain a profit fraudulently.

5. Billing Patients for Services that Weren’t Provided

In a similar vein as the above two types of fraud, doctors may also decide to bill patients for services they never actually performed. A healthcare provider is motivated to do this in order to make more money.

This type of fraud is often discovered when bills do not match the patient’s files.

If a medical service is actually provided, then there will be a record of it on the patient’s file. Often, investigators also need to ask the patient themselves whether they received the services they were billed for.

6. Shopping for Doctors

This type of healthcare fraud is committed by patients. Most often, patients have the specific intent of getting prescribed a certain medication.

Instead of simply getting the prescription for their medical condition, they’re actually attempting to get multiple valid prescriptions. The excess pills are used to sustain an addiction, or sold on the black market.

7. Medical Identity Theft

Just as someone can use your identity to steal money, people can assume your identity in order to receive medical care. The FTC recommends watching for the following signs of medical identity theft:

  • Receiving a bill for medical care that you never received
  • Phone calls or voicemails inquiring about a medical debt
  • A letter in the mail informing you that your insurance has been denied
  • A letter in the mail stating that you’ve reached your health plan’s benefit limit
  • Collection notices on your credit report regarding a medical debt

Correcting medical identity theft is just as complicated as fixing financial identity theft. In addition, it may be difficult for you to obtain proper health insurance after someone else has taken out a policy in your name.

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8. Prescribing Prescriptions Without a Medical Need

Well-informed doctors understand the risks associated with painkillers and opioids.

Even when used for medical purposes, these drugs are highly addictive. Sometimes, a doctor will prescribe painkillers without a medical need, but this action is a form of healthcare fraud.

Haphazardly prescribing these pills has serious consequences for both the patient and society as a whole. President Trump recently declared the opioid crisis a national emergency. Both doctors and patients have contributed to this disaster.

9. Waiving Deductibles

Often, patients are overjoyed when a doctor’s office waives their copayments or deductibles. That means a lower out-of-pocket cost!

This behavior, however, is prohibited by most government healthcare plans.

An immoral doctor’s office may decide to waive a patient’s co-pays or deductibles. Then, they overcharge or claim false charges to make up the loss. When they do this, they know the patient won’t complain because they didn’t have to pay out-of-pocket for the services.

Avoiding the Various Types of Healthcare Fraud

These nine types of healthcare fraud barely scratch the surface. If you’re practicing in the healthcare industry, then you need to be aware of these types of fraud. You’ll have to avoid breaking the law yourself, and you’ll also have to ensure your patients aren’t breaking any rules either.

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