18 U.S.C. Sec. 1347 HEALTH CARE FRAUD - ELEMENTS
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Other forms of fraud and abuse in health care. Billing for services not rendered medically necessary. Double-billing for services rendered. Billing for covered service when the service provided was not covered.
In California, healthcare fraud is considered a ?wobbler? crime, which means it can be charged as a misdemeanor or a felony. Typically, the prosecutor decides based on the amount of money involved.
Examples of Health Insurance Fraud Falsifying a patient's diagnosis to justify the need for tests, surgeries, or other procedures that are not medically necessary. Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery.
Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, or to sell, dispose of, loan, exchange, alter, give away, distribute, supply, or furnish or procure for unlawful use any
Common Types of Health Care Fraud Double billing: Submitting multiple claims for the same service. Phantom billing: Billing for a service visit or supplies the patient never received. Unbundling: Submitting multiple bills for the same service.
The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL).
Members can commit health care fraud by providing false information when applying for programs or services, forging or selling prescription drugs, using transportation benefits for non-medical related purposes, and loaning or using another's insurance card.
Examples: A physician knowingly submits claims to Medicare for medical services not provided or for a higher level of medical services than actually provided.