From: mha23x@gmail.com   
      
   The National Healthcare Antifraud Association   
   The Challenge of Health Care Fraud   
      
   Consumer Alert: The Impact of Health Care Fraud on You!   
      
   In 2011, $2.27 trillion was spent on health care and more than four billion   
   health insurance claims were processed in the United States. It is an   
   undisputed reality that some of these health insurance claims are fraudulent.   
   Although they constitute only    
   a small fraction, those fraudulent claims carry a very high price tag.   
      
   The National Health Care Anti-Fraud Association (NHCAA) estimates that the   
   financial losses due to health care fraud are in the tens of billions of   
   dollars each year.   
      
   Whether you have employer-sponsored health insurance or you purchase your own   
   insurance policy, health care fraud inevitably translates into higher premiums   
   and out-of-pocket expenses for consumers, as well as reduced benefits or   
   coverage. For employers-   
   private and government alike-health care fraud increases the cost of providing   
   insurance benefits to employees and, in turn, increases the overall cost of   
   doing business. For many Americans, the increased expense resulting from fraud   
   could mean the    
   difference between making health insurance a reality or not.   
      
   However, financial losses caused by health care fraud are only part of the   
   story. Health care fraud has a human face too. Individual victims of health   
   care fraud are sadly easy to find. These are people who are exploited and   
   subjected to unnecessary or    
   unsafe medical procedures. Or whose medical records are compromised or whose   
   legitimate insurance information is used to submit falsified claims.   
      
   Don't be fooled into thinking that health care fraud is a victimless crime.   
   There is no doubt that health care fraud can have devastating effects.   
      
   What Does Health Care Fraud Look Like?   
      
   The majority of health care fraud is committed by a very small minority of   
   dishonest health care providers. Sadly, the actions of these deceitful few   
   ultimately serve to sully the reputation of perhaps the most trusted and   
   respected members of our    
   society-our physicians.   
      
   Unfortunately, the stock in trade of fraud-doers is to take advantage of the   
   confidence that has been entrusted to them in order to commit ongoing fraud on   
   a very broad scale. And in conceiving fraud schemes, this group has the luxury   
   of being creative    
   because it has access to a vast range of variables with which to conceive all   
   sorts of wrongdoing:   
      
   The entire population of our nation's patients;   
   The entire range of potential medical conditions and treatments on which to   
   base false claims; and   
   The ability to spread false billings among many insurers simultaneously,   
   including public programs such as Medicare and Medicaid, increasing fraud   
   proceeds while lessening their chances of being detected by any a single   
   insurer.   
   The most common types of fraud committed by dishonest providers include:   
      
   Billing for services that were never rendered-either by using genuine patient   
   information, sometimes obtained through identity theft, to fabricate entire   
   claims or by padding claims with charges for procedures or services that did   
   not take place.   
   Billing for more expensive services or procedures than were actually provided   
   or performed, commonly known as "upcoding"-i.e., falsely billing for a   
   higher-priced treatment than was actually provided (which often requires the   
   accompanying "inflation" of    
   the patient's diagnosis code to a more serious condition consistent with the   
   false procedure code).   
   Performing medically unnecessary services solely for the purpose of generating   
   insurance payments-seen very often in nerve-conduction and other   
   diagnostic-testing schemes.   
   Misrepresenting non-covered treatments as medically necessary covered   
   treatments for purposes of obtaining insurance payments-widely seen in   
   cosmetic-surgery schemes, in which non-covered cosmetic procedures such as   
   "nose jobs" are billed to patients'    
   insurers as deviated-septum repairs.   
   Falsifying a patient's diagnosis to justify tests, surgeries or other   
   procedures that aren't medically necessary.   
   Unbundling - billing each step of a procedure as if it were a separate   
   procedure.   
   Billing a patient more than the co-pay amount for services that were prepaid   
   or paid in full by the benefit plan under the terms of a managed care contract.   
   Accepting kickbacks for patient referrals.   
   Waiving patient co-pays or deductibles for medical or dental care and   
   over-billing the insurance carrier or benefit plan (insurers often set the   
   policy with regard to the waiver of co-pays through its provider contracting   
   process; while, under Medicare,    
   routinely waiving co-pays is prohibited and may only be waived due to   
   "financial hardship").   
   Consider Some Risks of Health Care Fraud to You   
      
   False Patient Diagnoses, Treatment and Medical Histories   
      
   Health care fraud, like any fraud, demands that false information be   
   represented as truth. An all too common health care fraud scheme involves   
   perpetrators who exploit patients by entering into their medical records false   
   diagnoses of medical conditions    
   they do not have, or of more severe conditions than they actually do have.   
   This is done so that bogus insurance claims can be submitted for payment.   
      
   Unless and until this discovery is made (and inevitably this occurs when   
   circumstances are particularly challenging for a patient) these phony or   
   inflated diagnoses become part of the patient's documented medical history, at   
   least in the health insurer's    
   records.   
      
   A Boston-area psychiatrist, for example, forfeited $1.3 million and was   
   sentenced to several years in federal prison following his late-1990s   
   conviction on 136 counts of mail fraud, money laundering and witness   
   intimidation related to his fraudulent    
   billing of several health insurers for psychiatric therapy sessions that never   
   took place-using the names and insurance information of many people whom he   
   actually had never met, let alone treated. (He also went so far as to write   
   fictitious longhand    
   session notes to ensure phony backup for his phony claims. )   
   In fabricating the claims, the psychiatrist also fabricated diagnoses for   
   those "patients"-many of them adolescents. The phony conditions he assigned to   
   them included "depressive psychosis," "suicidal ideation," "sexual identity   
   problems" and "behavioral    
   problems in school."   
   Theft of Patients' Finite Health Insurance Benefits   
      
      
   [continued in next message]   
      
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