Page 363 - Ebook health insurance IC27

Sashi Publications

The most commonly observed types of fraud from a provider are:
 Patient not admitted in the hospital but claim generated
 Providers charging more than the peer providers for the same type of services.
 Billing for more expensive services or procedures than were actually not

provided or performed. E.g. billing for advanced life support services when
basic life support was provided.
 Double billing: Charging more than once for the same service.
 Billing for larger amounts of drugs than are dispensed; or billing for brand-name
drugs when less expensive generic drugs are dispensed.
 Billing for ambulance which was not required.
 Performing medically unnecessary services, investigations, surgeries solely for
the purpose of generating insurance payments. Eg performing angioplasty on the
cardiac patients which was not required.
 Misrepresenting non-covered treatments as medically necessary covered
treatments for purposes of obtaining insurance payments-widely seen in
cosmetic-surgery schemes, in which non-covered cosmetic procedures such as
"nose jobs," "tummy tucks," liposuction or breast augmentations, for example,
are billed to patients' insurers as deviated-septum repairs, hernia repairs, or
lumpectomies.
 Increasing the length of stay in the hospital. It has been observed that the Length
of stay in smaller hospital is much more then the larger set up.
 Managing insured patient's accounts by completing and submitting claims on
behalf of the patient. There have been instances when the member went for

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