Explain What Constitutes Fraudulent Billing

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Explain What Constitutes Fraudulent Billing



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There are many types of insurance fraud, but the judicial system often categorizes them as either hard fraud or soft fraud. Hard fraud occurs when a person intentionally fakes an accident, theft , or injury to collect money from an insurance company. For example, Tom has been unemployed for several months, when his old clunker car breaks down. Desperate for money to replace his car, Tom decides to make it look like someone broke into his house, then made a police report claiming theft of several expensive items. This type of hard insurance fraud is common, and is one reason insurance companies employ an insurance fraud investigator. Hard fraud cases almost always results in felony charges. Soft fraud occurs when a person has a valid insurance claim, but falsifies part of the claim, or exaggerates damages in order to obtain the maximum benefits.

Many people do not consider this to be as serious as hard fraud, but it is still a crime, and can result in increased insurance costs for clients. For example, Elizabeth is involved in a minor collision when someone backs into her car in a parking lot. There is substantial damage to one part of her car, and she is uninjured. When it comes to filing the insurance claim, however, Elizabeth reports having neck and back pain, and even seeks treatment by a chiropractor to support her claim of injury.

In this type of soft fraud, Elizabeth has a valid claim for damages to her vehicle, but she claims personal injury in an attempt to receive a higher payout. The exact amount of money lost due to insurance fraud cases is hard to determine, as the crime often goes unnoticed. The number of fraud cases that are actually caught is believed to be much lower than what actually occurs. The high cost of fraudulent cases is passed down to insurance customers in the form of higher premiums, as the insurance companies try to recoup some of those losses.

Life insurance fraud occurs when a person fakes their own death, or the death of another person, in order to receive life insurance payments from the insurance company. This type of fraud usually involves two or more people. When the life insurance company is notified of a death, the named beneficiary receives the insurance settlement. Many people committing life insurance fraud resurface years after the assumed death took place.

If the person is caught, the person who aided in the life insurance fraud scheme is charged with the crime as well. Life insurance fraud would be considered hard fraud and, because of the dollar amounts involved, is a felony. Another common form of insurance fraud occurs in the health care industry. Health insurance fraud is the act of deceiving, misrepresenting information, or concealing information with the intent to receive benefits. Both patients and providers can commit health insurance fraud. When patients commit health insurance fraud, it is usually by falsifying or altering forms, concealing pre-existing conditions, or failing to report information.

Medical providers can commit health insurance fraud by making false claims, billing for services not provided or supplies not used, or altering existing claims. It is believed that most healthcare providers that commit health insurance fraud do so in order to receive greater compensation that they normally would from Medicare or Medicaid. This can be done in several ways, including:. Health care fraud does not end with individuals and healthcare providers however, as health insurance companies themselves are known to have committed fraud.

They do this by deleting claims from their system, not paying claims, and denying coverage even if the person meets the criteria. Auto insurance fraud is a commonly perpetrated fraud in the U. Insurance investigators have even discovered some insurance adjusters getting in on the act for a fee. Perpetrators of auto insurance fraud use a variety of tactic, such as braking sharply in traffic to intentionally cause the car behind them to hit them in the rear. Another tactic used by those who engage in insurance fraud is jumping in front of a moving car and claiming that the car hit them.

Often, when unintentional accidents occur, and the victim will exaggerate their injuries to receive more money. They may even claim that the accident caused injuries that were in fact, caused by something else, in order to get their treatment paid for by the auto insurance company. For example, Armando waits in a busy parking lot for someone who is obviously distracted to back out of a parking space. While the individual is backing up, Armando slips in behind the car, banging loudly on the rear, then falling down to the ground. This allows the physician to meet the needs of the new strict HCFA mandate on clarity of all Medicare claims.

There is another part of the transitioning phase which is communicating post transition. During this phase the case managers are reaching out to the patients and their support system to see how things are going. This phase basically focuses on different types of outcomes of care like, financial, clinical, physical functioning, and more. The CM department can gather information of all processes concerning the treatment, nursing, and after-treatment of the patients to perform better services for patients Wulff et al.

Concerning the new strategy implemented by RWTH Hospital, the margin between estimated bed time and actual bed time has been. Reimbursement is the process in which the clinic will be reimbursed by an insurance company for the services we provide. We will be referring clients to the Giblin Physical Therapy Clinic for treatment and rehabilitation. Each athletic trainer should know how the aspect of insurance reimbursement works. Which means the minimum amount of rehabilitation minutes the patient must receive depending on what payment group the patient is a part of SLPs in Long-Term Care. These minutes include Occupational Therapist and Physical Therapy as well.

A Speech-Language Pathologist must be able to communicate with the other professionals, making sure each patient is getting the correct amount of minutes in each day. Medicare Part B is put into place when patients from Medicare Part A have used all of their minutes, but. At this particular outpatient clinic, the OTPF is used to identify and explain the meaning of certain terms such as IADL or purposeful activity to clients, family members, other practitioners, and insurance companies.

This framework is used when processing claims for insurance companies, and it can be seen when therapists use specific language to explains how therapeutic activities support health and function. When OTs collaborate at this facility, they use common language pertaining to OT which allows them to maintain service competency. The goal of the therapists at this facility is to work with clients so that they can perform their occupations as efficiently as. Mandal , Ananya. In cases where they have to carry out complex operations, they may have to request the assistance of other doctors. They may also need to purchase expensive equipment. Thus, the health costs not only lie with the patients, but also with the workers.

Proper making of policy can see that this issue is minimized. They analyze and extract important medical data from all pertinent records in order to create an organized chronology that highlights the medical care that was provided to an injured claimant before and after the date of injury. Medical chronologists examine billing records and summarize the costs in reports for medical experts. They evaluate medical records to verify the continuity of health care and find gaps or omissions in treatment. Medical chronologists prepare detailed summaries of all records and verify if the chronology objectives are clearly achieved and in accordance with all applicable policies and procedures.

Medical chronologists must be able to comply with established deadlines and legal timeframes to complete records reviews. In additional to the original threaded discussion, level one codes are based on the documentation used for CPT. It is also very important that every claim and any medical information is done through and acted by HIPPA regulation to ensure the patients privacy. When a patient first visit a medical facility a copy of the notice of privacy must be provided to the patient, this will explain how to exercise his or her rights under HIPAA. Be proficient in interpreting basic clinical tests as well as images. Provide initial treatment for emergency medical problems and recognize acute conditions.

Understand and use pharmacotherapy effectively and appropriately. Family medicine physician residents must be able to demonstrate their competence in managing maternity care within the scope of the family medicine guidelines. Competently perform surgical, medical and diagnostic procedures that are appropriate for their area of practice. Billing 1 Week 2 DB Discuss the importance of knowing the processes and procedures used for receiving payment for services rendered under the contract provisions.

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