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Health Care Fraud or Abuse

What is health care fraud or abuse? How is it defined?

Health care fraud or abuse is defined as being a pair of unethical and potentially illegal acts that can get a doctor or other health care provider into trouble. Health care fraud is the deliberate billing for a service that was never given or for a service that has a higher reimbursement than the service produced. Health care abuse is payment for services or items that are billed by mistake by providers, but should not be paid for by Medicare.

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Health care fraud occurs when an organization or person deliberately deceives someone else in order to get some sort of unauthorized benefit. Health care abuse takes place when a provider supplies a product or service that does not meet professional standards or is not medically necessary.

How big a problem is health care fraud or abuse in the United States? Does it affect all of us?

A problem that affects everyone

Whether you realize it or not, health care fraud or abuse does affect everyone in the United States either indirectly or directly. It is estimated that billions of dollars are lost as a result of healthcare fraud or abuse every year in the United States. As a result, these loses bring about increases in health care costs and the potential for increases in the cost of health care coverage.

To be more specific, health care fraud involves an intentional act of deceit or an intentional deception or misrepresentation in order to gain a greater reimbursement. Health care abuse involves reckless conduct or disregard that is not inconsistent with and goes against acceptable medical and/or business practices for the purpose of receiving a larger reimbursement.

There are several types of health care fraud or abuse that are perpetrated by health care providers. Some of these include:

Misrepresentation of the service that is being provided
Billing for a service that is covered, but the service that was actually provided was not covered
Billing for services that was not provided
Submitting duplicate claims for the same service
“Upcoding” - charging for a more expensive or complex service than was actually provided.

The bottom line is that health care fraud or abuse is a large national problem in the United States. Is there anything that can be done to fight health care fraud or abuse? Is there anything that you can do?

Here are some things that you can do to help fight and prevent health care fraud or abuse. They include:

Researching your health care providers with your state’s medical boards
Reporting health care fraud or abuse as soon as you possibly can
Protecting your personal information and insurance card at all times
Counting your pills every time that you get a prescription
Reviewing your explanation of benefits to make sure of things like names of providers, types of services reported and dates of service.

If you believe that you or your loved one has been a victim of health care fraud or abuse, it would be a good idea to talk to a personal injury attorney to make sure that your rights are protected.
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