What Does Health Care Fraud Look Like?

The majority of health care fraud is committed by organized crime groups and a very small minority of dishonest health care providers. The most common types of health care fraud include:

  • Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
  • Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
  • Performing medically unnecessary services solely for the purpose of generating insurance payments.
  • 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" are billed to patients' insurers as deviated-septum repairs.
  • Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
  • Unbundling - billing each step of a procedure as if it were a separate procedure.
  • Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
  • Accepting kickbacks for patient referrals.
  • Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.