Identifying Medicare Fraud And When It Is Committed

By Solomon Lowreoll

If you have information about a health care provider committing fraud on Medicare, you have a choice if you will just turn a blind eye or become a whistleblower. Because of whistleblowers, federal and state governments have been able to recover billions of dollars lost because of fraud.

Every year, billions of dollars are lost to scammers because people choose to simply shut up and take little care. People should be aware that aside from helping the country, they will also get rewards about 15-30% of the recovered value if they become whistle blowers.

There are several types of healthcare fraud or Medicare fraud being committed repeatedly by health care providers. One of them is charging for services that were never rendered and supplies that were never used. This is the most basic type of fraud being committed.

Medicare only reimburses services and supplies that are medically necessary. Medicare verifies this by requiring documentation indicating doctor's prescriptions and recommendations for the services rendered and supplies requested. Fraud is committed when health care providers falsify these documents just so they could charge Medicare.

Most of the procedures and supplies that are billed to Medicare are identified via codes. Each code has a corresponding charge as well as service that was rendered. Fraud is committed when a more expensive code is reported instead of the correct code for the real procedure. This type of fraud is called upcoding. Unbundling works differently though because instead of being charged together services are unbundled and charged via separate codes which definitely cost more. Some services are supposed to be part of a whole comprehensive package and therefore should not be unbundled and charged separately.

There are pharmaceuticals and medical devices that needs certification and approval by the FDA first before they can be sold off in the market. Medicare does not reimburse for items like these because techinically, its illegal to sell them yet. But there will always be non-approved off-label uses for this product and there will always be people who will tolerate them. Fraud happens when providers charge Medicare for non-approved or off-label usage. In order to be a whistleblower, there are pages online dedicated to Medicare fraud reporting. There is also the Medicare fraud hotline ready to accept calls for fraudulent activities being reported.

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