Medicare Fraud
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Types of Medical Fraud
"Phantom Billing" - Billing for tests not performed.
Performing inappropriate or unnecessary procedures.
Charging for equipment/supplies never ordered.
Billing Medicare/Medicaid for new equipment but providing the patient used
equipment.
Billing Medicare/Medicaid for expensive equipment but providing the patient
cheap equipment.
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 physician.
"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 anyway.
"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 Medicaid number.
"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 co-payments.
