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Flashcards in HEALTH CARE FRAUD Deck (29)
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1
Q

Definition

A

Health care fraud involves a deception or misrepresentation that an individual or entity
makes, knowing that the misrepresentation could result in some unauthorised benefit to the
individual or to the entity or some other party. The most common fraud involves a false
statement or a misrepresentation or deliberate omission that is critical to the determination
of benefits.

2
Q

Provider Fraud

A

Provider fraud is perpetrated by a physician, clinic, medical supplies vendor, or other provider
against patients to increase income

3
Q

Provider Services Charged but not Rendered

A

A provider might submit charges for services not performed. This type of fraud is difficult
to uncover because it involves an omission of activity.

4
Q

Provider Fraud Overutilisation

A

Overutilisation occurs when a physician prescribes unnecessary or excessive patient services

5
Q

Provider Fraud Unnecessary Medical Testing

A

A service provider advises an insured that additional medical testing is needed to diagnose
the problem. In fact, the testing is not required and the fee for the unnecessary work often is
split with physicians.

6
Q

Provider Fraud Fictitious Providers – Bogus Doctors

A

In this scheme an individual who is not a doctor opens a medical practice. The individual
obtains or creates a doctor’s ID number to appear legitimate. Thereafter, the fake doctor
bills the insurance company for the medical services.

7
Q

Provider Fraud Photocopied Claim Forms with Benefit Assignment Repeatedly Submitted by a
Provider with New Date of Service

A

In this scheme a provider alters a genuine claim form signed by the patient. This method is
usually used by a provider with a small business or by an accounting secretary who submits
fictitious bills for his own benefit.

8
Q

Provider Fraud Double Billing

A

Double billing occurs when the insured and/or the provider seek to be paid twice for the same service. The fraud might be perpetrated by the insured, with the complicity of the provider, or it might be done by the provider alone. The bill might be submitted to two (or more) different insurers, or it might be submitted twice to the same insurer with
documentation intended to show that two separate expenses have been incurred.

9
Q

Provider Fraud Fictitious Diagnostic Codes

A

A false billing takes place if the physician or other primary provider knowingly enters an incorrect diagnostic code.

10
Q

Provider Fraud Coding Fragmentation

A

Coding fragmentation involves the separation of one medical procedure into separate components to increase charges.

11
Q

Provider Fraud Mutually Exclusive Procedures

A

A variation of unbundling, this scam involves billing for procedures that are either impossible to perform together or, by accepted standards, should not be performed together.

12
Q

Provider Fraud Upcoding

A

Upcoding involves billing a higher level of service than was rendered.

13
Q

Insured Fraud Fictitious Claims

A

As with false claims submitted by providers, the insured quite often will submit bogus claims

14
Q

Insured Fraud Multiple Claims

A

The insured commits a fraud when he makes a claim for a covered loss without revealing
that he has already been paid for that loss. Such fraud may involve both fraudulent concealment of the prior claim(s) and payment(s) and misrepresentation that the loss has
been uncompensated.

15
Q

Insured Fraud Alteration

A

A dishonest claimant can inflate a prescription or medical bill by placing an additional
number in front of the amount charged. The claimant can also alter the date of service so
that it becomes a recoverable expense rather than one incurred prior to eligibility. The individual submitting a claim may change the name on the bill from an uninsured family member to one included in the insurance plan.

16
Q

Insured Fraud Ineligible Dependants

A

Mother, father, nieces, and sisters usually are not eligible for coverage under an insured’s
plan. Insurance carriers are sometimes informed of ineligible dependants by other family
members or by providers. Where possible, the examiner should obtain a written statement
from the informant. The statement should include the following:
• Name and address of the person receiving the treatment;
• The patient’s true relationship to the insured;
• A complete description of the person receiving the treatment;
• A complete physical description of the impersonator;
• Any other information that might be useful, such as signature and telephone number of
the informant and the date of treatment; and
• Complete hospital records, including the emergency room report, the admitting history,
and the physical description of the patient, if applicable.

17
Q

Insured Fraud Doctor Shopping

A

Patients may “shop” around for multiple doctors that will provide controlled substances.
However, one physician does not know that another has already prescribed the drug. In
addition, the patient may shop for drugs in emergency rooms complaining of soft tissue
injuries, sprains, and strains.

18
Q

Insured Fraud Third-Party Fraud

A

This category involves an unauthorised use of an insured’s identification card by another
known person or unknown person. The insurance company is usually notified by the insured
once they receive a benefit statement work sheet for services rendered.

19
Q

Insured Fraud Death of Insured

A

The primary insured passes away; however, the beneficiary does not notify the insurance
carrier and continues to submit fictitious claims on medical expenses after the death of the
insured.

20
Q

Red Flags

A

• Misspelled medical or dental terminology
• Unusual charges for a service
• Similar handwriting by the claimant and the provider of the service
• Typed rather than printed billings
• Bills with irregular columns
• Unassigned bills that normally are assigned, such as large hospital or surgical bills
• Drug receipts from the same pharmacy but on different paper
• Erasures or alterations
• Lack of any provider’s signature on a claim form
• Absence of the provider’s medical degree, i.e., “Dr. John Doe” instead of “John Doe,
M.D.”
• An illegible provider signature
• Pressure by claimant to pay a claim quickly
• Individuals who hand-deliver their claim and insist on picking up their claim cheque
• Threats of legal action if the claim is not paid quickly
• Continuous telephone inquiries regarding the status of a pending claim

21
Q

Detection

A

• Utilisation Review (UR) areas, which address overutilisation of outpatient services.
• Flag future claims of aberrant providers or insureds.
• Computer programs can be developed that identify excessive charges for prescription or
medical services above an acceptable level.
• Built-in claims edits can identify and reject duplicate submissions.

22
Q

Claims fraud using employee’s contract

A

—Claims employees generally have access to claims
data and claim forms. They can sometimes adjust claims or pull someone’s claim, change
the claimant’s contract number, and have the claim processed.

23
Q

Claims fraud using another insured’s contract number

A

Employees who have access to insured’s
enrolment file can locate an insured with a similar name as the employee. From there,
the employee can easily complete a claim form and submit the claims through the regular processing system. The employee only has to put their own address in order to have the
payment sent to them.

24
Q

Claims payment using a relative’s contract

A

—Employees can fabricate claims and submit them

under a relative’s contract number.

25
Q

Claims adjustment system

A

Claims that are legitimately paid incorrectly need to be adjusted.
An adjustment examiner can adjust a claim for fraudulent purposes also.

26
Q

Payment for cancelled contracts or deceased insureds

A

If an adjuster has access to the enrolment
files, he might run across a deceased insured. By submitting or processing a claim before
cancellation, an examiner can manipulate the claims system and divert payment to
himself.

27
Q

Improper payee

A

A claim approver overrides a claim payment system and pays out claims
to improper payees. The claim approver inserts her son and daughter-in-law as payee.
Cheques are submitted to an address other than the insured’s.

28
Q

The following steps can be used to determine if a company is dealing with an employee who is defrauding the system:

A

• Pull high dollar claim payments for insureds. Investigate all unusual patterns by verifying
services.
• Review printouts for special payee codes to search for employees.
• Review printouts for a high number of adjusted claims per insured.
• Review printouts of recently cancelled contracts for unusual claims activity just prior to
cancellation.
• Once unusual activity has been identified, follow normal investigative procedures.
• Review address change lists for employee names or unusual activity.

29
Q

Employee Claims Fraud Prevention

A

• Have a separate area to handle employee claims.
• Limit access to employee claims information.
• Have edits in the claims system which will generate exception reports for high dollar
claims payments and multiple adjusted claims.
• Make it known to employees that audits are regularly conducted.
• Require and enforce adjusters to sign off their terminals when not in use.