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Health Care Fraud - Don’t Do It!

By:  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Published:  July 31st, 2017

If you need to ask yourself if what you are doing is fraud, DON’T DO IT! The government takes this extremely seriously. I don't need to tell you this. 

I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate claim? In short, fraud is an intentional deception or misrepresentation.   

Let’s not panic; there is a distinction between intentional fraud and an error. In regards to the 46 year old Denver woman, it was proved to be intentional. This was not an accidental duplicate claim.

The OIG posted this article on July 27th, 2017. 

"Denver Woman Sentenced To 46 Months’ Imprisonment for Health Care Fraud"

The US attorney’s office reported, “According to United States Attorney Bruce D. Brandler, as a result of prior convictions relating to Medicaid fraud, Sensenig was excluded from providing healthcare to Medicaid beneficiaries. In order to obtain a position as a behavioral health consultant, Sensenig made false representations, including a forged background check, in order to hide her ineligible status. As a result, Medicaid paid approximately $84,500 for her services."

USA Today reported on July 13th, 2017:

"Jeff Sessions: 400 medical professionals charged in largest health care fraud takedown"

“Sessions said the suspects accounted for more than $1.3 billion in fraudulent transactions across more than 20 states, and at least 120 people were charged for their alleged roles in overprescribing and distributing opioids, making it also the largest-ever opioid-related fraud takedown.

Of the 412 charged in the year-long operation, 56 were physicians.”

Of course, the OIG has a most wanted fugitive list. If you ever decide you want your name on that list and make a contentious decision that is your goal in life, and you no longer need your license you worked so hard for, you can get on this list. Hint: you never want to be on that list, but just in case you have any questions about how to get on it, here are just a few areas of conduct that will certainly place your name on the OIG’s most wanted list.

  • Bill Medicare for durable medical equipment (DME) and supplies that either were not provided or were medically unnecessary
  • Conspiracy to defraud the United States
  • Commit health care fraud
  • Pay kickbacks
  • Money laundering 
  • Conspiracy to commit money laundering
  • Medical treatments that were never provided or were medically unnecessary
  • Aggravated identity theft
  • False claims
  • False statements related to health care matters
  • Falsification of records
  • False Medicare claims for durable medical equipment (DME) that was medically unnecessary or was not provided to beneficiaries

Some of the less obvious but common areas of fraud are just as serious, such as: 

  • Waiving patient co-payments and deductibles
  • Prescribing drugs unnecessarily
  • Inaccurate reporting of patient diagnoses and procedures

This list could go on-and-on. The other side to this is that it's not only payers and the government that pays for dishonest providers; the affect is far-reaching. Starting with the elderly, Medicare beneficiaries are commonly scammed using benefits that count toward a lifetime or other limited benefit. On an even more personal note, it is estimated that American taxpayers will pay between $50-90 Billion annually for Medicare fraud alone.

Most providers follow good medical practices, are outstanding providers, and take their oath seriously. The National Health Care Anti-Fraud Association (NHCAA) states the majority of healthcare fraud is committed by a very small minority of dishonest healthcare providers.”

We can all do our part by keeping an eye out for perpetrators of healthcare fraud. Lowering health care fraud and abuse should potentially begin to lower healthcare costs. This certainly affects all of us personally.

To report Medicare fraud, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you’re a TTY user, call 1-877-486-2048.


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