Overbilling: A Leading Cause of Healthcare Fraud

Overbilling is one of the most common types of healthcare fraud. It typically occurs when a physician or a billing office submits a claim for services never provided or gives a diagnosis that is more serious than the original diagnosis in order to gain greater reimbursement.

Overbilling and other fraudulent claims are rampant, as evidenced by many startling statistics. For example:

The total Medicare cost for fraudulent claims is over $50 billion every year. Ten billion dollars of this total is for overbilling and other phony medical billing.
Over the course of ten years, the University of Washington overbilled Medicaid and Medicare by approximately $100 million.
Kentucky-based Kindred Healthcare paid $1.3 million in an overbilling case to Tennessee's Medicaid program.

Of course, there are numerous additional statistics chronicling overbilling and other types of healthcare fraud perpetrated by physicians, hospitals, clinics, billing offices, and consumers as well. But overbilling is more than just startling statistics. Its effects are far-reaching in all areas of the healthcare industry. From billing or overbilling for durable medical equipment (DME) such as wheelchairs and hospital beds to chiropractors charging for massage therapy when they're really just using an "aqua-massage" table, overbilling is widespread and extremely taxing on the system. The money lost annually to overbilling and healthcare fraud could buy three years of insurance for every uninsured U.S. child according to the U.S. Department of Health and Human Services/General Accounting Office.

Fraudulent overbilling can be categorized into several areas:

Services not provided: As aforementioned, one of the most prevalent forms of overbilling occurs when a doctor submits a claim for a procedure he or she never actually performed, such as a surgery.
No medical value: Another type of overbilling happens when a healthcare provider submits a claim for inferior service that results in no medical value, such as a nursing home getting reimbursed even when they fail to properly feed a patient and results in the deterioration of his or her health.
Standard of care: Healthcare providers may also overbill for services or treatments that do not meet quality standards of care. This includes putting a patient at risk due to a healthcare provider's failure to take reasonable preventative action to safeguard his or her health.
Unnecessary treatment: This is another common practice that typically occurs when a doctor performs unnecessary medical tests and then fraudulently bills the insurance company.

To avoid becoming a victim of overbilling, everyone should check their explanation of benefits (EOB) on a regular basis for inaccuracies or irregularities, and notify their physician, clinic, hospital, billing office, and healthcare plan of any discrepancies.

Visit www.TheIdentityAdvocate.com or call 310-831-4400 to learn how to prevent the devastating effects of overbilling and healthcare fraud.

Author Box:

Linda Vincent, R.N., P.I., is an identity theft and healthcare fraud prevention expert specializing in medical consulting and investigations. She teaches corporations, professional practices, and consumers how to stop identity theft and healthcare fraud. Call The Identity Advocate at 310.831.4400 or email info@theidentityadvocate.com. Visit www.TheIdentityAdvocate.com.

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Overbilling: A Leading Cause of Healthcare Fraud

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