Medicare and Medicaid are government health insurance programs targeting specific people in society. Medicare is a federal health insurance program for adults aged 65 and above, young people with certain disabilities, and patients with end-stage renal disease. On the other hand, Medicaid is a federal and state health insurance program targeting low-income earners. With these two insurance programs, medical service providers and other professionals in the healthcare industry commit Medicare fraud to get payments they don’t deserve. Keep reading to learn more.
What is Medicare Fraud, and How Does It Happen?
In simpler words, Medicare fraud is a situation where a medical service provider knowingly deceives Medicare or Medicaid to receive payments when they should not. In addition, one can commit this fraud when they knowingly request and receive higher payments than they should. It is always a calculated move where medical experts use tricks to get money from the health insurance programs that they don’t deserve so that they can make more profits.
One of the situations where medical service providers commit this fraud is when they bill for services not rendered. Providers know that Medicare or Medicaid will not have a chance to ask patients about the services they received at medical facilities. So they take advantage of that and bill for service they know they did not provide to the patients. Others provide services that are not medically necessary and request payments for them from the health insurance program.
In addition, other providers use upcoding and unbundling to get higher reimbursements from Medicare and Medicaid. For instance, they can upcode by making a false diagnosis, hence billing more expensive procedures or exaggerating the amount of time they spend with the patients. There are many other ways the fraud can happen, but let’s now look at how to prevent it from happening.
3 Ways to Prevent Medicare & Medicaid Fraud
There are many ways to prevent medical service providers from defrauding Medicare and Medicaid. Here are three ways:
Report Fraud – If you have noted that a certain healthcare facility or service provider is asking for payment for services not rendered or using other tricks to defraud Medicare or Medicaid, you should report the facility or provider to the responsible authorities. You will be a whistleblower, and you will be protected by the law. In return, you will receive a monetary reward, and stern action will be taken against the facility/provider.
Improve Systems – Trusting health care providers is not enough to stop fraud. Medicare and Medicaid should improve their systems to ensure medical service providers only request payment for services rendered. System improvement will also eliminate incidences of upcoding and unbundling by providers.
Promote Proper Work Ethics – Besides reporting fraud and upgrading the billing system, Medicare, Medicaid, and society at large should run campaigns to promote proper work ethics in the healthcare sector. When healthcare facilities and medical service providers know that they should not make profits through Medicare fraud, incidences of fraud will significantly reduce. They will work hard and smart to make profits in the right way.