As health care consumers, we all eventually pay the price for fraud. While the majority of consumers are honest, a small percentage take advantage of the system. According to the National Health Care Anti-Fraud Association, about $68 billion is lost to healthcare fraud annually.
Potential Fraud Issues
- Billing for services not rendered
- Billing for "free services"
- Inaccurate reporting of diagnosis or procedures to maximize payments
- Misrepresenting actual services or dates of service
- Billing non-covered services as covered services
- Eligible providers billing for the services provided by a non-eligible provider
- Accepting or offering kickbacks or bribes
- Loaning out a member identification card
- Enrolling an ineligible dependent for coverage or not removing dependents when they are no longer eligible
- Altering the amount charged, date of service, or quantity amounts on a claim form or prescription
- Creating claims
- "Doctor shopping" which includes visiting multiple doctors and/or excessive trips to the emergency room in order to obtain controlled substances
More on Doctor Shopping:
- UCA:58-37-8 (3)(a)(ii) defines as unlawful "to acquire or obtain possession of, to procure or attempt to procure the administration of, to obtain a prescription for, to prescribe or dispense to any person known to be attempting to acquire or obtain possession of, or to procure the administration of any controlled substance by misrepresentation or failure by the person to disclose his receiving any controlled substance from another source, fraud, forgery, deception, subterfuge, alteration of a prescription or written order for a controlled substance, or the use of a false name or address.
- Any person convicted of violation the above is guilty of a third degree felony.
- A third degree felony is punishable by up to five years imprisonment, restitution and a fine of $5,000.