Most doctors are honest, and try to do the right thing.
A few aren’t.
Most often, they try to rip you off by ripping off your insurance company.
This isn’t a “victimless” crime. The victims here aren’t just the insurance companies, but the public at large, because the cost of physician fraud eventually gets passed on to everyone in the form of higher premiums.
In other cases, the patient experiences harm directly – in the form of higher direct expenses and unnecessary medical procedures.
Here are some of the more common ways physicians abuse the trust and authority we place in them and rip people off.
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Health Insurance Fraud
There are many different types of scams and ripoffs that physicians, dentists, and hospitals may commit to defraud patients and insurance companies. Some of the most common include:
- Billing for services not performed. This is a straightforward scam in which the provider bills for services that were never actually provided.
- Upcoding: Upcoding is the practice of billing for a higher level of service than was actually provided. This can be done to increase the reimbursement that the provider receives from the insurance company. Both billing for services never performed and upcoding can be difficult for insurance companies, health sharing plans, and other payers to detect, as the patient may not realize that they didn’t receive the services that were billed for.
- Billing for duplicate services. This is the practice of billing for the same service more than once. It can be difficult to detect, as the patient may not realize that they were billed for the same service twice.
- Unbundling (fragmenting). Insurers sometimes pay less for procedures normally performed together, such as incisions and closures incidental to surgeries. Unbundling – sometimes called “fragmenting,” happens when a provider separates multiple bundled procedures – sometimes across multiple visits – in order to claim the higher reimbursement rate.
- Waiving deductibles or copays. Some providers will waive deductibles or copays for patients who are willing to pay cash or who have certain types of insurance. This is a violation of their agreements with insurers, and it can lead to higher costs for other patients.
- Unnecessary procedures: Doctors and other medical providers may recommend unnecessary procedures to patients in order to increase their profits. This can be harmful to patients, as it exposes them to unnecessary risks and costs.
Example: In 2012, NextCare, Inc., an operator of urgent care clinics, was accused of defrauding federal and state taxpayers by improperly billing for medically unnecessary tests, such as H1N1 tests, allergy tests, and respiratory panels. The company paid $10 million to settle the allegations, while the whistleblower received part of an award of more than $1.6 million.
It is important for patients to be aware of the potential consequences of doctor conflicts of interest and to ask their doctors about any potential conflicts that may exist.
If you suspect that you have been the victim of a medical scam, you should report it to the appropriate authorities. You can file a complaint with the state medical board or licensing agency, or you can contact the federal Office of Inspector General.
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Conclusion
Patients should be vigilant against all attempts to rip them off, whether directly, as the patient, or indirectly, through their insurance companies, health sharing plans, and other payers like Medicare and Medicaid.
It’s a good idea to check your own doctors’ background and read up on any history of discipline or complaints.
For Further Reading: Why You Should Use Independent Doctors | Escape From Health Insurance Companies’ Narrow Networks – How You Can Choose Your Own Doctor | How to Find the Best Doctors | How To Escape the Health Insurance Scam
