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How does fraud occur in the healthcare space?

On Behalf of | Jan 31, 2024 | Criminal Defense

Healthcare, a field built on trust and compassion, is sometimes tainted by fraudulent activities. Healthcare workers entrusted with the well-being of patients can find themselves accused of fraudulent practices.

Understanding how fraud occurs in the healthcare space can help you proactively defend yourself against accusations.

Unauthorized billing

One common way fraud can occur is through unauthorized billing. Malicious healthcare workers may submit false claims for services that were never provided. They might also inflate the costs of legitimate services. This deceptive practice not only compromises the financial integrity of healthcare systems but also impacts patients who may bear the burden of higher costs.

Phantom patients

Fraudulent healthcare workers might also create phantom patients. These are fictitious individuals who supposedly receive medical services. By billing for these non-existent patients, healthcare workers can channel funds into their pockets while evading detection. This deceptive tactic exploits the administrative aspects of healthcare systems.

Kickbacks and bribery

Some healthcare workers accused of fraud engage in kickbacks and bribery schemes. This involves receiving illegal payments or benefits in exchange for patient referrals, services or the purchase of medical equipment. Such unethical practices compromise the impartiality and fairness that should characterize healthcare decisions.

Upcoding and unbundling

Upcoding is the process of billing for a more expensive service than the one actually provided. Unbundling involves billing separately for procedures that patients would otherwise pay for in a cost-effective bundle. Both practices distort the financial aspects of healthcare and lead to unjust enrichment for the accused individuals.

The United States Sentencing Commission reported that there were 431 healthcare fraud offenders in 2022. This is a 1.4% increase from 2018, meaning that fraud accusations, both rightful and wrongful, are on the rise in the healthcare space. It is important for healthcare workers to understand how they can defend their rights in the face of such accusations.