5 Common Types of Fraud In Health Care You Need to Know

Editorial Note: These blog posts represent the opinion of DoNotPay’s Writers, but each person’s situation and circumstances vary greatly. As a result, you should make sure to do your own independent research. Because everyone is unique, our self-help tools are never guaranteed to help with any specific situation. DoNotPay is not a law firm and is not licensed to practice law. DoNotPay provides a platform for legal information and self-help.

Get Your Money Back From 5 Common Types of Fraud In Health Care

Directly and indirectly, healthcare fraud affects all of us. For those who have not been directly involved, you have likely experienced increases in health insurance premiums and taxes due to various illegal healthcare schemes.

However, if you have been directly involved, you may have undergone unnecessary procedures, paid more for those you needed even with insurance coverage, and been subject to the same increase in taxes and insurance premiums.

No matter you may have experienced including with Medicaid or Medicare, you can get help through DoNotPay.

Common Types of Fraud in Healthcare

Not all healthcare fraud is committed by medical providers. Patients and other unrelated people also commit illegal healthcare-related acts all the time, including prescription forgery, identity theft, or impersonating a medical professional. But unfortunately, even true medical professionals, including doctors and nurses, are tempted to earn more money through fraudulent means. And often that happens to the older population through Medicare medical fraud.

Some types of medical provider fraud include:

  • CPT Upcoding
  • CPT Unbundling
  • Double billing
  • Phantom billing

Let's examine them more closely in this table:

CPT UpcodingCPT coding or current procedural terminology coding provides a set of five-digit numbers for every medical test and procedure. There are CPT codes for an office visit to your physician or having a blood test. When you have surgery, there are likely multiple codes applied, one for anesthesia, one for the surgery itself, and others for testing and hospital stays.

Upcoding is when a doctor or medical facility uses a code for a similar, but more expensive procedure than you had done. For example, you had a routine office visit, but the office charge was for an extended visit involving more of the doctor's time and therefore a higher charge.

CPT UnbundlingCPT unbundling occurs when multiple CPT codes are applied for a procedure that is an integral part of another. Again, the intent is to earn more money from your insurance company, and quite possibly you, than really should have been charged.

One example of unbundling could be if intravenous fluids are given and there is one charge for inserting the needle and another for providing the medications. One code could have been used for both.

Double BillingAs the name implies, double billing is the act of billing your insurance company for the same procedure twice or more, even though you only had it once.
Phantom BillingPhantom billing occurs when a provider bills your insurance for a test or procedure which you never had.
Other Fraudulent IssuesThere are still others such as overcharging for services or supplies, billing for services that were not medically warranted, and misusing CPT codes on a claim.

How the False Claims Act Applies to Healthcare

The False Claims Act (FCA) originated for protection against fraud following the Civil War and remains as an important piece of legislature today. The FCA is often utilized by attorneys pursuing false medical claims for their clients.

Through the FCA, billions of dollars have been recovered from doctors, hospitals, pharmacies, and pharmaceutical companies on behalf of U.S. taxpayers.

How to Deal with Healthcare Fraud by Yourself

If you see discrepancies between what you experienced in a medical office, laboratory, or hospital, and what you and your insurance are being billed for, you should:

  1. Report possible medical billing fraud to your health insurance, whether it is Medicaid, Medicare, private insurance, or a combination of two or all three.
  2. Demand the error be corrected directly to the medical office through a demand letter. For this, you will need to do your research, so you sound like you know what you are talking about. It will take time, and it can be complex and confusing.

You could also see an attorney and it may make you feel better, but unless the errors amount to a lot of money, it would not be cost-effective. Or you could use DoNotPay.

Ask DoNotPay to Deal with Your Healthcare Fraud Problem

DoNotPay is a legal app, designed to handle just such a problem as healthcare fraud. By entering a little data, DoNotPay will look up proper CPT codes, write a demand letter for you, and send it to the medical provider. If necessary, through DoNotPay's Sue Now option, the app will prepare a small claims lawsuit against the provider or hospital.

To put DoNotPay to work simply:

  1. Search Fight Medical Fraud on DoNotPay.

  2. Tell us the date of your visit, what you were treated for, and where you were treated.

  3. Let us know what CPT code your visit was filed under. If you don't know, we'll generate a letter for you to send to your physician to request the code.

  4. Choose the correct CPT code or let us know if you want us to find it for you.

  5. And that's it! DoNotPay will automatically find the correct CPT code for your visit if you don't know it and then generate a demand letter on your behalf to send to your physician for a bill correction.

DoNotPay Can and Will Do More

The ingenious DoNotPay app will take care of many issues beyond writing a demand letter for healthcare fraud. It can also:

While DoNotPay is writing your demand letter, check out what else it can do for you.

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