5 MAJOR TYPES OF HEALTHCARE FRAUD INVESTIGATIONS

5 MAJOR TYPES OF HEALTHCARE FRAUD INVESTIGATIONS

The health status of individuals influences their productivity within the society. Everyone wants to be strong and healthy to enable them to carry out their daily activities. It is on this basis that individuals access healthcare services to improve their general well-being.

However, there seems to be a growing trend of fraudulent claims within the healthcare system which violates the integrity of the healthcare system. In most cases, private investigators are hired to bring the offenders to book and curb this form of corruption. This article highlights the different forms of healthcare fraud that can be investigated while securing an improved system.

Understanding Healthcare Fraud

Healthcare fraud refers to a situation where individuals file fraudulent or dishonest claims to benefit from the settlement. It is a white-collar crime that impacts on taxpayers and the society at large. Every year, billions of dollars are expended on settling claims that are not legitimate. This epidemic cripples the ability of healthcare providers to render esteemed services due to limited access to funds.

Investigation and Indictment for Healthcare Fraud Schemes

The Healthcare fraud schemes have been on a rise in recent times with reports of several indictments. In April 2022, it was reported that a physician was charged for a $10 million fraud scheme in respect of false claims. Further, the Department of Justice in the United States reported that this individual charged dozens for millions of dollars in healthcare fraud. Many cases investigated result in the suspension of healthcare providers, convictions and recovery of millions of dollars in the interest of the general public.

Prior to indictment and charges, investigators are often needed to gather evidence, conduct interviews, review information, and analyze claims. The reports from the private investigators include the final recommendations that are communicated to law enforcement, attorneys, and organizations to enable the prosecution of the white-collar crime.

Forms of Healthcare Fraud

One of the most prosecuted crimes is healthcare fraud with the government investing in the recovery of funds on behalf of taxpayers in the country. The recovery is made from hospitals, patients, pharmaceutical companies, doctors, and even pharmacies. It has become noticeable that personal injury attorneys contract the services of medical practitioners to obtain favorable settlement for their clients. This propels the resort to private investigators to uncover healthcare providers and patients that attempt to rig the system. The different ways this fraud is committed include—

1.Generating False Reports

This involves situations where reports are falsified in respect of the patient’s medical condition. In most cases, the disease or medical condition is non-existent. It is on record that attorneys, especially in personal injury claims send cases to orthopedic surgeons or chiropractors to write reports. When settlement is made in favor of the client, the medical practitioner participates as a beneficiary of the fraudulent scheme.

2. Misrepresentations

This covers misrepresentations made in respect of the services rendered or individual who rendered the services. When generating reports, medical practitioners may fail to document the procedure, or make a wrong diagnosis to exploit the patient’s situation. The intention behind such decisions is often the desire to increase the patient’s bills.

3.Inappropriate billings

Patients are often billed for services that were neither provided to them nor documented for reference. It also covers instances where patients are billed for services and items that are not necessary. This is recognized as a prevalent form of fraud in the healthcare system for which medical practitioners have been indicted on several occasions.

4.Unbundling Services

Unbundling is a systematic fraud in which the healthcare providers charge separately for a single procedure. It covers situations where the services are fragmented to enable the healthcare providers make more profit from the services. For example, there was a 2014 settlement where anesthesia and cardiac services were billed separately even though anesthesia was a part of the cardiac procedure.

5.Upcoding

This applies to when the healthcare providers charge the patients for services that appear to be similar to the actual services rendered but is of a higher nature. It may include where the healthcare providers code a muscle strain as complications that require surgery. The projection enables the healthcare provider to charge higher than is necessary for the services that is being rendered to the patient.

The other forms of healthcare fraud include the use of another person’s healthcare benefits to settle one’s personal needs, obtaining multiple prescriptions from different doctors, or making false claims to benefit from the worker’s compensation program and insurance schemes. For healthcare providers, there are proven instances of dispensing less drugs than prescribed while charging the prescription amount. This guide also acknowledges that healthcare providers accept kickbacks in event of patient referral.

The Role of Private Investigators in Preventing Healthcare Fraud

Private investigators may elect to browse through the affected party’s files to identify possible issues or unusual activities. It is also a norm for them to interview close friends, neighbors or coworkers to discover the truth. If the evidence gathered shows any inconsistencies, it becomes beneficial in preventing the exploitation of the healthcare system.

When undertaking private investigation, working with an investigator that has a law enforcement background can be a great advantage. This is because with their knowledge of the law, they will have the skills to address spontaneous cases. It is also recommended that you work with a private investigator that is responsive to enable you to apprehend the white-collar criminals.

Based on investigation reports, it is important that the employees within the healthcare sector are educated to preserve the system’s integrity. The sensitization of the public on the implications of healthcare fraud and ongoing prosecution cases may curb the fraud levels in certain geographical areas when a fraudster is caught, and it is made known to the public.

Conclusion
Healthcare fraud is a growing epidemic that affects the efficiency of the healthcare system. The use of private investigators has proven helpful in recovering funds from indicted persons. There however exists a collective responsibility on every member of the society to ensure that fraud cases are prevented and reported to enable a successful investigation of perceived fraud.

Author: Christopher M. Cavallo is a seasoned security professional and private investigator and as President of CSI Secure Solutions specializing in insurance fraud investigations providing such services as OSINT research, comprehensive background/social media ,hidden-asset discovery, witness location and complex surveillance operations on a nationwide basis.

Insurance Fraud Investigator