Practice Area - Philadelphia Healthcare Fraud Defense

Healthcare Fraud

What is healthcare fraud?

Healthcare fraud is the misstatement of facts – either knowingly or through unreasonable ignorance – that leads to unfair profit through medical coverage. Healthcare fraud encompasses false claims by physicians, managed care organizations, and numerous others. It also includes overpricing or incorrect invoices from manufacturers and distributors of such products as pharmaceuticals and wheelchairs. Healthcare fraud can even include individuals, such as those who attempt to gain coverage through a false identity.

What are the different types of healthcare fraud?

Healthcare fraud can occur on numerous levels. There are many ways in which a claim may be falsified, and various institutions that may be responsible. The following is a collection of the some of the most common methods of executing healthcare fraud.

Perhaps the most common form of healthcare fraud is the misstatement of services rendered or goods provided. The goods/services may never have been given; some blatant scams set up shop with the specific purpose of obtaining insurance information and filing claims for fictitious medical treatment. However, many organizations have been known to engage in the subtler practice of “upcoding,” in which a claim contains a more expensive product or service than the actual one. This occurs in private practice, for example, when a doctor claims to have investigated symptoms of pneumonia in a patient that was never tested for anything more than a common cold.
Healthcare organizations are also infamous for charging unreasonable rates. Several high profile cases of government fraud have included healthcare equipment distributors that acquired their goods for pennies, then redistributed them at a cost of tens of dollars apiece to the government. But, just as with charging for services not rendered, there are less obvious ways of getting away with high rates. Physicians and other providers sometimes resort to a technique called “unbundling.” Unbundling involves splitting up the charges for a comprehensive procedure for which one all-encompassing charge is the industry standard. Each individual procedure can then be marked up without drawing as much attention.

Thirdly, some healthcare providers have been know to provide treatment that is completely unnecessary. This most often occurs in instances such as the pneumonia example, with the difference being that the attending physician actually performs the check even though the symptoms do not call for it.

Some providers have even combined personal expenses with their claims for medical care.
“Kickbacks” – illegal incentives given for the performance of a service – are not infrequent in the healthcare industry. Benefits agents may recommend one company’s plan over another’s in exchange for money. Or, in the course of care, an attending physician may recommend special treatment from one of his fellow providers over another with the knowledge that he’ll be paid for such a referral.

Consumers can also be guilty of healthcare fraud. One example is forging family names to provide coverage to friends. Consumers have also been known to encourage their provider in the forgery of claims with the intention of dividing up the reimbursement.

Contact the the Philadelphia Law Offices of Attorney William Spade

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Law Offices of William Spade
1525 Locust Street • Philadelphia, PA 19102 • Phone: 215-732-3001 • Fax: 215-732-0124 • E-Mail: info@spadelaw.com