Two types of potential Medicaid or Medicare fraud are double billing and phantom billing. These do have some similarities in that they are issues with the way Medicaid is billed by healthcare providers, but they are also a bit different. Whistleblowers need to be aware of both potential types of fraud and how they differ.
With phantom billing, the products or services being billed for were never rendered in the first place. Say that a dentist’s office bills Medicaid, claiming to have given a patient a root canal, but that is simply not a procedure they ever received.
A slight variation of this is known as upcoding, when more expensive services are charged. Maybe a person had a minor procedure at the dentist’s office, but they are billed as if they had a major operation. This is also potential fraud, even though some medical services were provided.
Double billing issues
With double billing, the issue is that the claim is being submitted twice. The procedure was carried out and services were rendered, but Medicaid was then billed for them twice, rather than just once.
This could be incidental, perhaps an issue of miscommunication at a doctor’s office or a dentist’s office. It could also be a paperwork error, where claims are accidentally submitted twice instead of just once. But if it is done intentionally, then it could be a form of Medicare or Medicaid fraud.
The role of intent is very important, as is differentiating between violations like double billing or phantom billing. All whistleblowers involved in this process need to understand what legal steps to take.