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5 Most Common Types of Medical Billing Fraud And How To Protect Yourself

posted by Chris Valentine

With great knowledge and expertise comes great responsibility. That holds true for many industries, with healthcare being on top of those fields. We always look up to those working in the healthcare industry, as they perform some of the noblest jobs on earth. They have a sacred responsibility to take care of our health, in turn, we give them complete trust and credibility. They are the experts, after all. The sad truth is that, while there are many noble and ethical practitioners, some view their jobs merely as a business practice. And business means finding ways to make more money – even if it’s at the cost of the trust they are given. This becomes a serious issue when they turn to defraud their medical billings to make some extra cash.

Here are the 5 most common types of medical billing fraud and what you can do to protect yourself against this illegal practice:

1.  Wrong Diagnosis or Drug Prescription

There’s a simpler way to make more money, which is to order for more tests and prescribe more drugs to you. However, in order to do that, you need to believe you need those tests and drugs. So, they convince you by giving you a wrong diagnosis, after which you’ll be forced to comply in order to take care of your health. Giving a wrong diagnosis is a great way to force countless unnecessary procedures on the patients, even when they don’t need them at all.

To protect yourself from being a victim of this practice, you should always take a second opinion and visit a physician only if you need to. For instance, Medicare professionals on explain how plans F and C of Medigap were discontinued to new enrollees starting 2020. The main reason was that, as these two plans cover Part B of doctor visits, tests, and outpatient procedures, patients will be forced to make sound decisions on their own on whether or not they should receive these services.

2.  Upcoding and Fragmentation

When you’re charged for more expensive services than those you’ve received, this is upcoding. Instead of being charged for the sprained ankle treatment you’ve received, you find the bill issued for a broken ankle. You might have gone for a checkup only to find yourself paying for a procedure. Although this practice takes up only 2% of the fraudulent medical billing cases, the costs are enormous.

Fragmentation is another form of upcoding. While upcoding charges you for a more expensive procedure, fragmentation takes apart the procedure you’ve received to charge you for every step as a separate procedure. For instance, Medicare beneficiaries usually get their benefits in the form of packages that include all the services provided under one bill. By taking apart these procedures and billing you for each one of them separately, they’re able to make more profit.

To avoid falling into these scams, always make sure to review your bills and the services documented before paying them. In the case of finding any discrepancies, make sure to make inquiries and notify your health insurance company.

3.  Overcharging and Inflated Bills

In other cases, you might be charged for the correct services, but still, your bill doesn’t look right at all. The numbers are much higher than they’re supposed to be. If this is the case, you should demand a billing investigation to find out where these costs are coming from. You’ll probably find that you’ve been overcharged.

4.  Phantom Billing

So, you’ve heard of upcoding and overcharging. What you’ll never expect to hear about is phantom billing: when you’re charged for a service you haven’t received at all. You might have even been in the comfort of your house when you get the bill. When this happens, make sure to inform your insurance company and hire billing investigators to get to the bottom of this.

5.  Self-Referrals and Kickbacks

Did you know that it’s illegal for a doctor to give self-referral to do operations or other procedures? Some still do, but you should realize that’s illegal and most-probably fraudulent. There are very high chances that you don’t really need this operation. Other doctors go about it in a roundabout way; they refer you to other physicians to whom they have a connection. By doing so, they get a financial commission or some sort of a gift for referring patients to them, which is known as kickbacks. If you’re faced with this situation, it’s better to get a second opinion from someone else.

Despite its noble practice, many healthcare practitioners perpetuate medical billing fraud. In efforts to make more money, they practice different types of fraud to exploit their patients and their insurance providers. This practice affects everyone in the ecosystem, so always make sure you’re alert to protect yourself.

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