What is involved in a Healthcare Fraud Investigation?

Now-a-days Medicare fraud is becoming a headache for the government, and society also. Yet the goal is always the same - to rook money from the Medicare program. It occurs when physicians or suppliers fail to follow best medical practices, resulting in unnecessary costs to Medicare such as improper payments, or medically irrelevant services. In fact, Medicare fraud - estimated now to total about $60 billion a year - has become one of, if not the most profitable, crimes in America. Health care fraud is a crime which is not roaming around only to the health care provider level but there are other major contributors like patients, health care taxpayers, employers, insurance plan sponsors, and health care vendors also.

The individuals and organizations who are committing healthcare fraud either directly or indirectly can be punished with civil and/or criminal penalties.  Examples which indicate health care frauds are:

•    A health care program caused either directly or indirectly which involves the unnecessary cost

•    Reselling the medicines

•    Paying the bill in an inappropriate way

•    Illegally receiving Medicaid services

•    Allowing others to use your medical card

•    Obtaining duplicate prescriptions

•    Using more than one medical card

Some important factors related to Icfeci health care fraud investigation are:

This type of fraud can be charged as both a civil and a criminal offense. Identification of health care fraud is conducted through many private, local, state and/or federal agencies.

How the Investigation Starts

•    It will be an analyst who uncovers a claim that he or she regards as doubtful.

•    An insider can file a report to the authorities.

•    A dissatisfied patient can file a complaint.

After Receiving the Letter from a fraud Investigator: what is the next step?

The Inspector General employs a host of investigators and auditors who are expert at spotting inconsistencies and unusual patterns in purchasing and billing. The investigator starts the investigation process by evaluating the information in the complaint to determine the truth of actual misconduct, and then to classify what exact laws, rules, and/or policy may have been violated. Important areas to be addressed may include:

Documentation- was the medical treatment documents as medically necessary or not? Is this completely and correctly documented in the patient's health care record?

Dictatorial Laws and Rules- The administrative law for the State, with the scope of practice, training, supervision, and delegation are checked by them to spot whether the service provider is involved or not?

What can I do if I am being Investigated?

•    You can bring a lawyer to the interview.

•    You can consult with a lawyer

•    You may remain silent.

  Health Care Fraud Investigation Plan:

To reach the root level of fraud the investigator will identify potential witnesses. They will require other helpful information, such as patient and files of insurance claim that may possess proof of the misconduct. After the successful investigation they will collect all relevant proof which indicates the laws, rules and/or system governing health care have been violated.

Dan James is a renowned expert on health care fraud issues and can investigate cases relating to false billing, offering health care services without a license, false insurance claims, false diagnoses, and unauthorized surgery, forcing patients to undergo tests or surgery solely for pecuniary gains, staged accidents, kickbacks in patient referrals, and Medicare/Medicaid billing schemes.