What Does Healthcare Fraud Look Like?
Everybody is involved when it comes to health care fraud because there is no exclusion.
Indeed, only a small percentage of health providers and consumers are deliberately involved in medical fraud. Besides, even a small amount of health care fraud may increase the cost of health benefits for everyone.
What is Health Care Fraud?
Health care fraud is a crime. It is compromised when a dishonest health care provider or consumer has intentionally or causes another person submitting false or misleading information for use in determining the amount of health care benefits he will obtain.
Examples of Provider Health Care Fraud are:
- Billing for services not rendered
- Falsifying a patient’s diagnosis to justify surgeries, test or other procedures that are not medically necessary.
- Misrepresenting procedures performed to obtain payment for services not covered, such as cosmetic surgery services.
- Upcoding – billing for a more expensive service than carried out
- Unbundling – check each step of a procedure as if it were a separate procedure
- Accepting bribes for patient referrals
- Patient copayments or deductibles waiver and excess billing the insurance company or benefit plan.
- Billing a patient more than the amount of co-payment for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
Examples of Consumers Health Care Fraud:
- Submission of claims for services or medications not received.
- Forging or altering bills or receipts.
- Using insurance coverage or someone else’s card.
- This past year our Team of Investigators had a case where a local Dr. was working in conjunction with a patient and a pharmacy. The Dr. had diagnosed a patient who was in excellent health with a disease that required a very expensive protocol of tests and medications that were filled by a participating pharmacist. Our responsibility as an Investigative Agency to the Insurance carrier(client), was to prove the collusion and fraud by documenting and filming this activity and showing the relationship between the Doctor, Pharmacist and Patient on a monthly basis.
How to Avoid and Prevent Health Care Fraud
Here are some easy ways you can get protected from health care fraud and keep costs of health care low for people:
- Make enquires about the services you receive, such as: Why are they needed? How much they cost?
- Complete, sign and date a claim form at a time.
- Question advertisements or promotions that offer free trials, treatment or services – especially when the provider asks for your insurance information or a copy of your Healthcare ID card.
- In general, be wary of disclosing your insurance information. Protect your Health care ID card. It represents your benefits.
- Compare your healthcare investigations or your medical bills with your records. Are the dates of service right? Were the services listed carried out effectively?
- For those with managed care coverage, know about the charges that exceed the amount of your copayment asked to pay by a provider.
- Let us know if a provider has a practice of waiving copayments or deductibles.
- Report suspected fraud to Special Investigations.
CSI-Secure Solutions will help to Minimize Health Care Fraud
The team of our Special Investigators is responsible for minimizing the risk of health fraud. CSI-Secure Solutions will help to identify suspicious claims and stop fraudulent payments to suppliers and punish wrongdoers. CSI Secure Solutions also works with state and federal law enforcement and regulatory and other insurance companies to detect and prevent health care fraud. The CSI-Secure Solutions team includes trained professionals with experience in research, health care, nursing, law enforcement and accounting.
CSI Secure Solutions are members of the following organizations
International Association of Healthcare Security and Safety(IAHSS)
South Florida Claims Adjusters(SFCA)
Florida Association of Licensed Investigators(FALI)
American Society of Industrial Security(ASIS)
Chris Cavallo has been involved in every facet of the Security and Investigations Industry for over 35 years. He started his career with the two largest Security and Investigation Companies in the world at the time. Chris spent his first 2 years as a Management Trainee conducting witness interviews, surveillance operations, tracking down hard to find witnesses, missing children and 11 months in the field as an Undercover Operative. After completion of this program Chris quickly rose through the ranks and became a highly recognized Security Consultant for his first 10 years in the industry. He is considered a subject matter expert in various Security/Investigative practices such as Protective Services, Security Systems Integration and Background Investigations. He ended is corporate career with a Fortune 50 Company as the VP of the SE Region . He then co-founded a company, RSI Investigations (Records Search Inc.), which was one of the pioneers and leaders in the Background Screening industry in the late 80’s and also recognized as an INC 500 company. After this experience Chris founded Cavallo Associates working with Security, Defense and Investigation Companies and helping them develop their Business Plans and training their personnel while opening new markets in such places as Rome, Italy the Panama Canal and Bogota, Colombia. Today Chris is a Florida Licensed Private Investigator and continues to dedicate himself in the Security-Investigations Industry, sponsoring and developing several PI Interns while operating under the brand name CSI Secure Solutions headquartered in Davie, Florida and offices in Bogota, Colombia. Chris and his wife Caryn Rae Robin a local singer and popular voice coach live in Plantation, Florida with twin daughters Stefanie & Cristina and are very proud Grandparents of 5, Christopher 11,Stefan 9,Legend 6, Roman 5 and Mia Robin 4.