Medicare is the federal health insurance program for those over the age of 65 and for those who have certain disabilities. This program funds millions in healthcare services every year, and some allegedly try to defraud the system for personal gain.
One type of Medicare fraud involves making improper payments. In 2019, according to the Centers for Medicare and Medicaid Services, improper payments amounted to $28.91 billion. There are many ways improper payments can occur, and the four below are the most common.
Inefficiencies can result in waste that costs the Medicaid program more than necessary. For example, a practice that orders more diagnostic tests than necessary contributes to inefficiency.
Those who make mistakes while billing the Medicare system commit fraud. For example, if an employee uses an incorrect code to bill for a procedure, fraud can occur.
Not following the rules
Those who defraud the Medicare system may not follow proper procedures for billing. For instance, upcoding is a type of fraud that involves unnecessarily billing for more serious procedures in the event of a minor injury.
When someone bills for procedures or services a healthcare provider did not actually offer, Medicare fraud can occur.
Medicare fraud charges may occur even if the person charged did not knowingly or intentionally contribute to inefficiencies, make a mistake, disobey the rules or engage in deceit. Those who face charges for this crime may need to prove that their involvement was not intentional and simply a result of human error.