Health insurance frauds some years ago were at their peak (it still is, but has been reduced drastically, thanks to additional verification modules being implemented); however the chances of insurance payers getting duped nowadays are pretty low. Patient verification data, and private information which earlier was exposed to outsiders due to technical glitches has been sorted out as most largest medical billing companies use sophisticated software's that keep all your information safe as a locker.
When we talk about insurance fraud or abuse, there are still many people in the medical industry of how actually it happens. Read below to know more.


Most insurance reimbursement blunders are basic billing mistakes and not the result of a doctor, supplier, or provider trying to exploit Medicare. A fraud occurs when somebody purposefully distorts data or swindles Medicare. A typical case of fraud is deliberately charging Medicare for administrations that were never given or received by the patient. Most doctors, suppliers, and providers are focused on giving great care to patients and to billing DME equipment or services provided. Tragically, some people and organizations are resolved to duping or abusing Medicare.

A recently conducted survey by the American Medical Association appraises that outright fraud accounted for between $90 billion and $300billion in wasteful healthcare spending in 2015-16 or potentially up to 23% of total national healthcare expenditures.

Here Are Some Relevant Examples Of Medicare Fraud:

  • An insurance provider charges Medicare for administrations never received by the patient.
  • A provider charges Medicare for Durable Medical Equipment never received by a patient.
  • Somebody utilizes someone else's Medicare card to get medical treatment, supplies and DME.
  • Somebody bills and codes for home medical equipment even after it have been returned.
  • A company offers medications that are not approved by Medicare.
  • An organization uses fake information to mislead someone into joining a particular Medicare plan.


Abuse in health insurance claims management occurs when physicians or providers don't follow the regulations Medicare expects. It is critical to recognize fraud and abuse: Fraud is activity with the end goal to cheat or bamboozle Medicare for unlawful monetary gain. Abuse might be deliberate and combined with fraud. However it is frequently the result of poorly managed medical records and top of that incorrect medical billing, which sometimes goes un-noticed.

Also, one needs to remember that Abuse is not the occasional, accidental billing error, but an organized malpractice that leads to overbilling and waste of Medicare services. Abuse causes improper payment, duplication of services, failing to discontinue services that are no longer medically necessary, or providing services or equipment that is not medically necessary.

Various government statutes characterize Medicare fraud and abuse. Punishments for infringement can be serious, incorporating rejection from participating in all federally financed medicinal services projects, fines, and even detainment.

The Health Care and Fraud Prevention and Enforcement Action Team (HEAT) works in conjunction with local, state and government organizations to battle Medicare fraud and abuse that takes away the hard earned money of a DME facility, ASC, outpatient facilities, hospitals and clinics.

One thing medical professional should by now know is that though deterrence is difficult to quantify, there is empirical evidence that investigating and prosecuting healthcare fraud has resulted in reductions in improper claims to Medicare.

Published By - Medical Billers and Coders
Published Date - Dec-20-2017 Back

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