Aspects of Healthcare Fraud Detection and Prevention

The healthcare industry is highly regulated and the costs are monitored closely. Even so, the amount of money the government loses through fraud is enormous. This forces the state tax department and the federal government to a good amount of resources for investigating healthcare insurance fraud. Any individual or organization found guilty of committing healthcare fraud is liable to criminal or civil penalties. Providers are found to make many of these Medicaid and Medicare frauds and there are many reasons for this. One has to become aware of how an investigation may begin and what one’s options are once an investigation begins. One must also be aware of the potential penalties and have some knowledge of the local laws governing healthcare both at the federal and state level. 

Becoming familiar with healthcare fraud

Detecting and preventing fraud is the gamut of dharbor. We are the pioneers of Know Your Customer and Know Your Provider platforms in the USA. Our field of specialization is the detection of fraud and risk management for the same. Instances of Medicaid and Medicare fraud are these:

  • Providing double-billing for Medicaid or Medicare along with a private company. The treatment is the same. Double-billing also occurs when a patient attempts to charge the service using a separate bill and then includes the charge in the bill for a group of tests.
  • Making use of billing code that results in a higher charge for the services.
  • Making use of unwanted services.
  • To get Medicare or Medicaid services you give or receive something valuable.
  • Using paid references from beneficiaries of the healthcare system.
  • Billing for failed appointments. 

Start of an investigation

The most common way a healthcare fraud case investigation starts is when an analyst views a claim pattern as suspicious. Or, the authorities might get a tip-off from an insider or a whistleblower. Or else, it might just be a patient who is angry and files a complaint. You find a host of auditors and investigators who have an uncanny knack for recognizing inconsistencies in billing and purchasing patterns. So, you might receive a letter from the investigator asking you to provide specific documents or they may just want to interview you. Be sure of one thing, anything you say can be used to convict you of fraud even when you are “not the target of the investigation.” 

Take the proper perspective

You have to be aware of your rights. You can ask for and get a lawyer to be present at the interview. There is no need for you to answer any of the questions. Or, you may consult your lawyer and then give your reply. 

Penalties and consequences

Investigating fraud is the correct field for digital harbor inc. We help investigators uncover facts and recover the amount due as penalties. Here is a list of consequences and fraud penalties if you are found guilty:

  1. Orders for restitution.
  2. One could lose their medical license or have it suspended.
  3. Criminal prosecution and incarceration is possible.

Many of the cases happen to be genuine billing errors or misunderstandings. Medicaid and Medicare are governed by complicated laws. A violation will naturally result in legal penalties and have further consequences on the medical practice.

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