Healthcare fraud, specifically through programs like Medicare and Medicaid, is a major problem in the United States. In fact, it is one of the most prevalent types of insurance fraud committed each year. It is estimated that Medicaid fraud amounted to approximately $140 billion in 2016, while Medicare fraud was very close behind. So who foots the bill and gets hurt when fraud is perpetrated? In the situation of health insurance fraud in nursing homes, the victims are our loved ones.
Medicare coverage is broken into sections, starting with Medicare Part A. Part A covers inpatient hospital care, skilled nursing facilities (i.e. nursing homes), home health care services, and hospice care. Medicare is designed to assist persons over 65 years old and those who are disabled pay for medical expenses. For instance, an individual in a nursing who must undergo a procedure would only pay a percentage of the total cost. The remainder is billed by the medical provider to Medicare, who pays the provider an amount negotiated in advance for the specific procedure performed.
Medicare fraud can occur in a number of different ways. Some of the most common occurrences of fraud include phantom billing and kickback fraud. Phantom billing is probably the most obvious and widely committed type of fraud. This type occurs when healthcare providers bill Medicare for unnecessary medical procedures or procedures that are never performed. Unnecessary procedures can cause side effects that cause complications with a patient’s existing medical conditions. Billing for unnecessary medical equipment or tests also constitutes phantom billing. Kickback fraud refers to when another individual or facility receives some form of “kickback” for assisting in Medicare fraud. This could be criminals who steal patients’ Medicare numbers and data or medical providers receiving money for making false diagnoses or needlessly recommending a patient to another facility that will engage in financial fraud.