decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Diagnostic Tests / Fraud Alerts / Fraudulent billing pattern for diagnostic tests
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Article Overview
This alert summarizes a healthcare fraud pattern involving diagnostic testing billed to Medicare and private insurers. It explains the general structure of the suspected scheme, the types of services involved, the entities that raised the alert, and why payers were advised to watch for unusual billing patterns. The article is relevant to compliance staff, auditors, coders, investigators, and payer program integrity teams.
Why This Topic Matters
The article highlights a diagnostic-testing fraud pattern that affected both public and private insurance programs and caused significant financial loss. It helps readers recognize the broader compliance and billing oversight issues associated with suspicious testing volume and clinic activity.
What You Will Learn
- How a diagnostic-test fraud alert was described by anti-fraud authorities
- What general billing and referral patterns raised concern
- Why payer review and monitoring were recommended for unusual testing activity
- How suspected clinic and insurance misrepresentation can affect program integrity
Who Should Read This
- Medical coders
- Compliance officers
- Medical auditors
- Healthcare fraud investigators
- Payer integrity teams
- Billing managers
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