Is not seeing patients but billing for them considered healthcare fraud?

Is Billing under Medicare Advantage Capitated Contracts when the Patient has not been seen illegal?

Companies that intentionally enroll Medicare Advantage patients, and then fail to bring the patient into the office for initial medical assessment or failing to provide the patient access to medical care, and then billing for it.  Sometimes companies fall into billing for incarcerated patients, or patients that are out of the designated service area or even outside the country.  Not removing these patients from the billing system could lead to fraud upon the government.  Healthcare employers and healthcare whistleblowers are on the lookout for billing for patients that do not receive the appropriate services. 

According to the U.S. Department of Justice

Fraud in our nation's health care system, including that in the Western District of Michigan, results in losses of millions of dollars every year from the Medicare, Medicaid, and private insurance programs. Beneficiaries and other recipients of health care pay for these significant losses through higher premiums, increased taxes, and reduced services.

Health care fraud occurs when an individual, a group of people, or a company knowingly mis-represents or mis-states something about the type, the scope, or the nature of the medical treatment or service provided, in a manner that could result in unauthorized payments being made. Examples of health care fraud include:

Billing for services not rendered or goods not provided;

  • Falsifying certificates of medical necessity and billing for services not medically necessary;
  • Billing separately for services that should be included in single service fees;
  • Falsifying plans of treatment or medical records to justify payments;
  • Misrepresenting diagnoses or procedures to maximize payments;
  • Misrepresenting charges or entitlements to payments in cost reports; and
  • Soliciting “kickbacks” for the provision of various services or goods.

Health care fraud may be perpetrated against all types of health insurers and health insurance companies, including Medicare, Medicaid, Blue Cross Blue Shield, workers compensation, and other private entities. Medicare services are divided into Part A and Part B coverage. Part A coverage includes hospital care, home health care, and skilled nursing care; Part B coverage includes physician services, laboratory tests and x-rays, outpatient services, and medical supplies.

In Michigan, United Government Services, LLC, processes Medicare Part A claims, and Wisconsin Physicians Service Insurance Corporation processes Medicare Part B claims. For Part A and Part B, Trust Solutions, LLC, is the Program Safeguard Contractor (PSC). PSC's are contracted with the Centers for Medicare & Medicaid Services to reduce fraud and abuse in the Medicare program.

For approximately five years, fiscal intermediaries and carriers for Medicare have been required, in virtually all circumstances, to send notices and explanations of benefits to Medicare users and patients. It is critically important that all beneficiaries review and verify the information on these documents–and that they question any entries or notations that are inconsistent with or unrelated to the actual health care services provided. In particular, you should be especially attentive to and questioning of notices and explanations that memorialize:

  • Payments for any medical services, treatment, supplies, or equipment that you did not receive;
  • Dates of service or provision of items that differ from the dates on which you actually received the service or items;
  • Payments for ambulance transportation that was not provided to you; and
  • Duplicate payments for the same service or items or for home medical equipment while you were hospitalized.

In addition, you should be especially cautious if a health care provider tells you that:

  • A test or certain equipment is “free” but your insurance number is required for “record purposes”;
  • The more tests given, the “cheaper” they are;
  • Your insurance company can be convinced to pay for the services rendered or the equipment provided; and
  • Your insurance company will pay for the services rendered or the equipment provided–if an incorrect diagnosis or inaccurate description is communicated to it.

Anything else that strikes you as unusual or troubling about any oral statements or written reports given to you in connection with your medical care should prompt you to take further action to ensure that you are not a victim of health care fraud.

Ben Mirza is not only an attorney but was formerly a CPA, with a masters of public health.  There are over 100,000 attorneys in Florida, less than 500 of whom were ever Certified Public Accountants, and even less have the trifecta combination of law/finance/strategic healthcare background.   The benefit of this combined and layered skillset works well for clients who want an advocate to approach the issues holistically.  

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