Featured6 Popular Health Care Provider Fraud Schemes You Should Be Aware Of

Healthcare provider fraud is one of the fastest growing crimes that are being committed today. As a matter of fact, medical insurance companies are increasingly becoming aware of it, and their response is to implement new programs and rules that would help prevent this form of fraud from ever happening again.

But, there are still some people who don’t know what they can do to protect themselves from becoming victims of such a fraudulent activity. In your case, you must know how to detect and report healthcare provider fraud because, in the future, you might be forced to face all the consequences if you end up being one of those victims who were cheated out of their insurance money. To avoid this, it is undoubtedly a good idea to seek legal assistance. Such professionals are well-versed with the Health Care Law and help you steer clear of the potential fraudulent activities.

That being said, below are the six popular healthcare provider fraud schemes you should be aware of.

1. Being Billed For Healthcare Services Not Performed/Rendered

One of the most popular fraud schemes committed by healthcare providers is billing patients for services not actually rendered. This means that medical providers or their facilities would submit claim forms to insurance companies and other government healthcare plans for care and services that weren’t even given to the patients. This usually happens when the corresponding patient files have no supporting documents that would prove the performance of the services stated in the claim forms.

In such cases, the healthcare provider has the intention to defraud the insurance companies and government agencies so they can make easy money.

2. Kickbacks And Bribery (Corruption)

Despite the laws in place that penalize hospital fraud, there are still some healthcare providers who commit acts of corruption. These can include the unlawful receipt of payment and other forms of bribes for referrals and other services. The healthcare providers would take advantage of a person’s unfortunate situation just to perform their fraudulent acts. They would use their authority and power to unjustly enrich people for their personal gain and benefit.

In addition to bribes, kickbacks are also a common fraud scheme among healthcare providers. Despite the prohibition imposed by the state and federal laws, they’re still demanding cash payments from patients and doctors in exchange for referrals. This is how kickback violations in hospital fraud occur in the healthcare industry. If you’re a victim of this scrupulous act, don’t hesitate to contact a lawyer who specializes in hospital fraud for legal advice.

3. False Reporting Of Diagnosis To Bill Unnecessary Tests

This is one of the most performed fraudulent activities among some healthcare providers. Generally, false reporting of diagnosis is considered a fraud when the provider billed the insurance companies and government agencies for services that aren’t really necessary. Meaning, they would usually misrepresent the diagnosis and symptoms on the patient’s record to conduct unnecessary tests and procedures. For example, a patient has consulted a doctor for a cold treatment and conducted the appropriate tests, but the insurance company was charged for another diagnosis that requires different kinds of testing.

4. Misrepresentation Of Dates Of Service

Along with the technological innovations that revolutionized the healthcare industry, this sector continuously faces some issues on claims misrepresentations attributed to medical providers around the globe.

Another fraudulent scheme that you should be aware of is the misrepresentation of dates of service. This usually occurs when the provider reported they attended and treated the same patient in two separate days instead of one day. According to most insurance policies, each office visit should be billed separately, which is why they take advantage of misrepresenting the dates of service to make more money.

Therefore, if you want to protect yourself from such type of scheme, always check the dates of service in your claim form to make sure you get the insurance money that you rightfully deserve, not the healthcare provider.

5. Double Billing

There’s a fraud when the healthcare provider obtains payment from two sources for the same medical service. For example, a provider who participates in a drug study receives payment from pharmaceutical company while billing the insurance company for the same service. This is a deliberate example of double billing.

6. Waiving Of Deductibles

Typically, most insurance companies and government healthcare plans prohibit medical providers from waiving patients’ deductibles. However, despite the prohibition, some of these providers still do so and submit false claims to insurance companies to get the difference. In other words, the fraudulent provider would include other false services to the claim forms to increase their unlawful gains. After all, they’re confident that the patient will not complain because their deductibles were already waived by them.


Healthcare fraud is a crime that’s not tolerated by any government. Hence, you should be very careful in finding out what type of healthcare provider fraud has been committed against you. Keep in mind that you shouldn’t be afraid to contact your doctor if you think something isn’t right because the doctor is your best source of information and they know exactly what’s going on with your health.

On the other hand, if you suspect that your provider has been committing one of the schemes mentioned above against you, it's best to contact a lawyer immediately. Your lawyer will be able to advise you on how to best deal with the situation.

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Digital Health Buzz!

Digital Health Buzz!

Digital Health Buzz! aims to be the destination of choice when it comes to what’s happening in the digital health world. We are not about news and views, but informative articles and thoughts to apply in your business.

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