Healthcare fraud is a much bigger problem in the United States than many people realise. Any conscientious nurse who cares about the health and wellbeing of the medical system as a whole should be vigilant in looking out for healthcare fraud.

What Are the Consequences?

Most healthcare fraud is prosecuted under the Federal Health Care Fraud Statute – 18 USC 1347 | Healthcare Fraud Group LLC. Also known as the ‘Federal Healthcare Statute’, this legislation sets out broad prohibitions and the severe penalties for breaching them.

The Federal Healthcare Statute is used to prosecute a variety of activities associated with Medicare or Medicaid fraud. Nurses can help to prevent the proliferation of healthcare fraud by looking out for and reporting the telltale signs. Below are some of the most common forms of healthcare fraud and how nurses can spot and report them.

Phantom Billing

Phantom billing occurs when a healthcare provider charges an insurance company for services not rendered. For example, a healthcare provider might submit a claim for a powered wheelchair for a patient, despite the fact that the patient in question never received the equipment. Phantom billing can also occur when medical supply companies submit false claims for equipment allegedly for a healthcare facility like a hospital to insurers.

Phantom billing can cost the Medicare program a significant amount of money every year. Any nurses who suspect that they have witnessed phantom billing should report the incident to the relevant authorities as soon as possible. 

Billing for a Non-Covered Service

Many experimental treatments available in the United States, while promising, are not covered by the majority of healthcare plans. In these cases, doctors cannot provide such treatments and bill them to insurance companies just because they think they will be beneficial to the patient.

Most patients are understandably only concerned with getting better and minimizing their costs. Therefore, it is not reasonable to expect patients to identify cases of billing for a non-covered service. However, any nurse or healthcare professional who thinks that the doctor they work under is rendering non covered services and erroneously charging an insurance provider should immediately record the incident.

Mis-recording the Dates a Service Was Provided On

Some healthcare providers will make more money if they report that they visited and/or treated the patient on two different days, rather than a single day. Each of these visits can count as an office visit for the purposes of billing insurance providers. Nurses have a responsibility to be vigilant and to make sure that all paperwork is filled out correctly, including the appropriate dates.