Medicare Fraud: The New Menace in the Health Sector

In the present scenario, employees of the government sector, as well as the private sector, are given healthcare insurance to help them in times of emergency or medical conditions. But as the system is not flawless, many people take advantage of this and try to gain more and more money in the name of medical emergencies from the system. This leads to the birth of medical fraud.

What is Medical Fraud?

It is the intentional misrepresentation of a medical condition by an individual, medical service provider or an insurance company to gain money or medical benefits from it. It is reckless disregard for the proper codes and reimbursement rules, which in turn increases the reimbursement to the medical services provider. In order to avoid being behind bars, one must have the knowledge of the system. Legal’s healthcare fraud guide provides a person with all the things one must know.

Types of Medical Fraud

Various types of medical fraud schemes have surfaced in recent years. Some them are:

  • Unbundling – Billing each step of a medical service being provided to be used as separate procedures
  • Upcoding – Billing of services at a higher level
  • Card sharing – Sharing of an individual’s insurance ID to be used by another person for gaining medical benefits
  • Unnecessary Billing – Intentional and unnecessary billing of medical services and items not provided in medical care
  • Collusion – Willingly collaborating with insurance holders to file unnecessary claims to gain greater reimbursement
  • Drug Diversion – Prescribing drugs not necessary for treatment or writing falsified prescriptions in order to obtain drugs to sell them
  • Multiple Cards – Duplicating an individual’s insurance card and selling it to someone else so that he can gain medical benefits
  • Program Eligibility – Filing incorrect information in a person’s medical bill so that he may qualify for medical benefits

Theft of Individual Insurance Benefits

Private sector insurance provides a limited amount of benefits. Some medical service providers file a false claim against a person’s insurance card to increase the amount of money received for the services provided. Once this kind of false claim is paid, money gets deducted from the person’s limited insurance.

Medical Identity Theft

Sometimes an individual’s data is used to file false claims without the knowledge of the insurance holder, which leads to false information behind added to an individual’s medical record.

Physical Harm to Patients

In order to make more money, some health care providers intentionally and deliberately make patients undergo medical procedures which are entirely not necessary. This can make the patient face life-threatening conditions just for the sake of money.

Avoiding Medical Fraud

As per the Legal’s medical fraud guide there is a lot a person can do to prevent and avoid intentional or unintentional medical claims.

  • Always give a thorough read to the policy and benefits statement you take out from your insurance company.
  • Don’t share your medical insurance information with any salesperson, over the phone or on the Internet.
  • Always keep a record of the medical services you received so that you may report any fraud or false claim made in your name to the insurance company.
  • Always inform your insurance provider if you suspect that you are a victim of medical insurance fraud.

Medical fraud is a problem which is escalating day by day. Individuals must pay attention to the services they are being provided, and should always ask if the treatment being given is required or not. In case of suspicion, always report the provider to the authorities.


Photo by Marcelo Leal on Unsplash