The pandemic stretched the health care system beyond its limits, causing waiting rooms to overflow with those trying to get treatment and hospital beds to be hard to come by. While things have settled down in the spring of 2022, the aftermath of the last few years provides opportunities for bad actors to siphon money from a system flush with money earmarked to deal with the national emergency.
These are unprecedented times, but fraudsters’ schemes are similar to those used before the pandemic. However, just because we have seen them before does not mean they will fail. Someone often needs to speak up. Here is a list of common but effective schemes:
Bypasses provide opportunities
The fast-tracking was done for billing during the pandemic. The reason was to avoid disputes or changes to COVID-related care. Fraudsters could use this as an opportunity to bill inappropriately. For example, there may be billing submitted tests like respiratory pathogen panel that did not occur.
Unbundling services
This is a persistent problem in healthcare. Either intentionally or inadvertently, providers may bill separately for overlapping services. They may also break out a single procedure and submit multiple claims. Those concerned about fraud can check the patient’s records (if they have access) to review patient procedures conducted the same day.
Upcoding or excessive testing
Excessive testing is commonly used to run up bills. Sharp-eyed whistleblowers may see a higher than the average number of tests (compared to others getting similar treatments). Different healthcare systems have different protocols, but excessively high numbers compared to others should be noted and examined. Upcoding involves incorrect billing codes submitted for larger reimbursements from healthcare carriers. With 7800 different CPT codes to pick from, this is an easy way to overbill unless someone reviewing the billing sees a pattern.
Say something if this happens
There are mistakes in medical billing due to human errors, misunderstandings and technical issues. Those who identify troubling patterns such as the three outlined above will know what to look for. They may then realize that it is an issue that they should report.
