Frauds committed by hospitals are on the rise, and there is an urgent need for auditing of medical bills and ither medical expenditures. There appears to be a serious malpractise going on , where the patient as well as the Medicare or Medicaid schemes are facing a lot of losses. There are many reasons for this. Mostly patients simply do not know about all the services they have received and all what they were billed for; the rules concerning medical insurance are not transparent, so hospitals are finding ways and means to circumvent them.
There are not enough audits of bills being done, and finally there is a greater problem with those patients taking medicaid since unlike medicare, these patients do not get full explanation of medical benefits. The various means of frauds committed are :When the patient is admitted to the hospital, a simulataneous bill is also made for the out patient department. Thus the hospital is able to claim benefit by showing that the patient has been discharged and claims the Diagnosis Related Group (DRG) Payment.
For example the billing of a patient who has been diagnosed with enteric fever. Once the diagnosis is made, the hospital may show the patient as discharged and claim outpatient billing as well as diagnosis related billing. Thus the hospital does fraud by making two modes of billing. It is important to know that the diagnosis related compensation is once the diagnosis is made, and is not relevant to the actual stay period. Thus there is a bit of ambiguity here on this issue. Overbilling and billing for sevices that were not rendered.
Thus a patient may be billed for multiple hematological tests when in fact only a few were done. There is a common situation of the hospital overcharging on the OT time. Since compensation from the insurance agencies is based on the amount of time that a surgery took, often the billing may be made erroneously. Thus cross checking is vital. Still other hospitals may decide to place the illness in a category where higher compensation is claimed, like passing of a breast reducition surgery as prophylactic mastectomy to prevent cancer.
There are cases of hospitals perfoeming unnecessary procedures on patients like surgeries which were not required to claim Medicare benefits. Another kind of fraud has been the issue of kickbacks, wherein the patient and the hosptial collude to show procedures that were nover performed, and claim the medicare benefits. Then there is a local exchange of the ‘kickback’. Double billing has also been seen. Wherein the hospital bills both the Medicare as well as the Medicaid or any other insurance firm, for the same patient or the same preocedure Human error cannot be counted out.
To err is human. A simple typographical error may be the cause of overbilling, so a bit of thought may be given to that. Charitable institutions are also under the scanner. They have been seen to overcharge persons with limited or no insurance, once the treatment is taken, so people need to be on the look out for such situations. Referance 1. Hospital Billing Errors and Fraud. Accessed fromwww. fraudguides. com/medical-hospital-billing-errors. asp on 12 June, 2008 2. U4 Publication: Fraud in hospitals. Accesed from www. u4. no/news/? 14=fraud-in-hospitals on 12 June, 2008 3.