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Types of Medical Fraud
"Phantom Billing" -
Billing for tests not performed.
Performing inappropriate or
Charging for equipment/supplies
Billing Medicare/Medicaid for new
equipment but providing the patient used equipment.
Billing Medicare/Medicaid for expensive equipment but providing the patient
A drug or equipment supplier
completing a Certificate of Medical Necessity (CMN) instead of the physician.
"Reflex testing" -
Automatically running a test whenever the results of some other test fall
within a certain range, even though the reflex test was not requested by a
"Defective Testing" - When
a test or part of a test was not performed because of technical trouble (ie:
insufficient or destroyed sample, machine malfunction) but is billed for
"Code Jamming" - Laboratories
inserting or "jamming" fake diagnosis codes to get Medicare/Medicaid
coverage. Offering free services of supplies in exchange for your Medicare or
"Unbundling" - Using two
or more Current Procedural Terminology ("CPT") billing codes instead
of one inclusive code for a defined panel where rules and regulations require
"bundling" of such claims. Submitting multiple bills in order to
obtain a higher reimbursement for tests and services that were performed within
a specified time period and which should have been submitted as a single bill.
"Double Billing" -
charging more than once for the same service, for example by billing using an
individual code and again as part of an automated or bundled sets of tests.
"Up Coding" - Inflating
bills by using diagnosis billing codes that indicate the patient experienced
medical complications and/or needed more expensive treatments. (eg., billing
for complex services when only simple services were performed, billing for
brand-named drugs when generic drugs were provided, listing treatment as having
been for a more complicated diagnosis than was actually the case.)
"Phantom Employees" -
Expensing employees or hours worked that do not exist.
"Improper Cost Reports" -
Submitting false cost reports seeking higher Medicare reimbursements than
permitted by actual facts.
Providing Substandard nursing home
care and seeking Medicare reimbursement.
Routinely waiving patient
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