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Table 2 Manifestation of health insurance fraud by the provider

From: Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review

Manifestation

Description (examples)

Studies

By the provider

Self -referral

A scheme for recommending patients to their own or third-party provider has a financial relationship with the originator of the referral. (a)

(Francis, 2020)

Upcoding

Intentionally coding a health claim based on an inaccurate use of codes to obtain greater economic value. (b)

(Gasquoine & Jordan, 2009; Massi et al., 2020; Palutturi et al., 2019; Phillipsen et al., 2008; Sheffali & Deepa, 2019)

Unperformed or billing for services not provided

Known as phantom billing, claims are presented for medical services, medications, medical devices not delivered to the patient.(c)

(Aral et al., 2012; Bauder & Khoshgoftaar, 2020; Bayerstadler et al., 2016; Brooks et al., 2012; Dolan & Farmer, 2016; Gasquoine & Jordan, 2009; Jou & Hebenton, 2007; Lee et al., 2016; Li et al., 2008; Palutturi et al., 2019; Perez & Wing, 2019; Phillipsen et al., 2008; Smith et al., 2013; Yang, 2003)

Misrepresenting the diagnosis or procedure to justify payment

Manipulation of procedures, diagnoses, requests, complaints, dates, frequency, duration or description of the services provided. (d)

(Gasquoine & Jordan, 2009; Li et al., 2008; Phillipsen et al., 2008; Shin et al., 2012; Yang, 2003)

Soliciting, offering, or receiving a kickback

A bribe is defined as a financial or other advantage offered, granted, requested or accepted in exchange for privileges or treatment.(e)

(Gasquoine & Jordan, 2009; Perez & Wing, 2019; Sheffali & Deepa, 2019)

Unbundling or exploding charges (bundled services are supposed to be paid at a group rate)

Creating separate claims for services or supplies that should be grouped. It can be seen as part of an incorrect codification, but several authors mention it as a separate form of fraud. (f)

(Bayerstadler et al., 2016; Gasquoine & Jordan, 2009; Li et al., 2008; Manocchia et al., 2012; Palutturi et al., 2019; Perez & Wing, 2019; Phillipsen et al., 2008; Shin et al., 2012)

Falsifying certificates of medical, plans of treatment, medical records.

It is manipulating documents (clinical history, invoice, clinical exams, prescriptions or certificates), prices, and services to achieve economic benefit. (g)

(Dolan & Farmer, 2016; Gasquoine & Jordan, 2009; Jou & Hebenton, 2007; Li et al., 2008; Lin et al., 2009; Manocchia et al., 2012; Phillipsen et al., 2008; Sheffali & Deepa, 2019; Victorri-Vigneau et al., 2009; Yang, 2003)

Unjustified services, Overutilisation, Providing unnecessary care

Providing unnecessary medical care or Billing more expensive procedures or services. (h)

(Bayerstadler et al., 2016; Dolan & Farmer, 2016; Francis, 2020; Jou & Hebenton, 2007; Li et al., 2008; Palutturi et al., 2019; Perez & Wing, 2019; Wan & Shasky, 2012; Yang, 2003)

Opportunistic fraud,

Billing for services provided by unqualified personnel without credentials or licence to give that type of care. (i)

(Aral et al., 2012; Phillipsen et al., 2008; Weiss et al., 2015)

Repeat billing or billing twice for the same service provided

Charging more than once for the same procedure, medications and medical devices, even if they are only administered once. (j)

(Dolan & Farmer, 2016)

Readmission or admission

Readmissions apply to hospitalized patients who require prolonged treatment (administratively discharge), dividing them into two episodes when they are not discharged. (k)

(Palutturi et al., 2019)

Type of room Charge

Billing the cost of care for a room whose treatment class is higher than the one used by the patient. (l)

(Palutturi et al., 2019)

Cancelled services, Underbilling or “write-offs” such as professional discounts and courtesies.

Involve the billing of medications, procedures or services previously planned but then cancelled, includes billing of discounts and professional courtesies provided. (m)

(Dolan & Farmer, 2016; Palutturi et al., 2019)

By the subscriber

Using the wrong diagnosis to justify payment

Medical reimbursements are sent by filling out claim forms for a service provided based on a diagnosis. These diagnoses can also be manipulated. (n)

(Shin et al., 2012)

Price and documents manipulation

It is manipulating documents (clinical exams, certificates, medical prescription, among others) to achieve an economic benefit. (o)

(Bayerstadler et al., 2016; Dolan & Farmer, 2016; Lin et al., 2009; Manocchia et al., 2012)

Unperformed billing for services not provided

Patients file false claims alone or in collusion with friends or healthcare professionals to collect fraudulent medical reimbursement. (p)

(Ekin et al., 2018;Li et al., 2008 ; Yang, 2003)

Opportunistic Fraud

It is a case of opportunistic or occasional fraud, one in which “the reality of a claim is taken advantage of to introduce pre-existing or previous damages”. (q)

(Ribeiro et al., 2020; Zhou et al., 2016)

Identity fraud included using ghost or deceased employees.

Obtain and use someone else’s health insurance card to get health care or other services. This situation can occur with or without the knowledge of the owner. (r)

(Baltussen et al., 2006; Dolan & Farmer, 2016; Goel, 2020; Jator & Hughley, 2014; Johnson & Nagarur, 2016; Li et al., 2008; Sheffali & Deepa, 2019; Shin et al., 2012)

Doctor shopping

Patients seek to stock up on controlled substances or drugs. (s)

(Sheffali & Deepa, 2019)

Misrepresenting eligibility

Patients can misrepresent information about themselves or their dependents to obtain medical coverage, which is not eligible. (t)

(Geruso & Rosen, 2015; Li et al., 2008; Sheffali & Deepa, 2019; Yang, 2003)

By the insurer company

Falsifying benefit or service statements

Agent or insurer who falsifies statements of benefits or services. (u)

(Li et al., 2008; Yang, 2003)

Falsifying reimbursements

Agent or insurer falsifying reimbursements. (v)

(Li et al., 2008; Yang, 2003)

  1. a) Refer patients to a clinic, diagnostic service, hospital, among others, with whom they have an economic relationship; if the referred pays a commission, a bribe could be configured (Thornton et al., 2015)
  2. b) One nurse coded CPT 99212 “problem-focused office visit for a patient” with no history or physical exams in the medical record; she just got a tetanus booster. The coding identified the patient with back pain, which the patient denied, a false diagnosis coding was identified (Phillipsen et al., 2008)
  3. c) The insurance company received a bill for USD 600 for CPT Code 93980 (for the penile duplex scan), USD 300 for CPT code 54240 (penile plethysmography), USD 95 for CPT code 59504 (for a nerve conduction study) and USD 165 for CPT code 99214 E&M (no history or detailed exam). The medical file contained a “Vascular Profile for Free Diagnostic Evaluation” sheet signed by the professional, which consisted of a vascular profile and biotelemetry of the penis (Barrett, 2006)
  4. d) A patient visit before a planned vasectomy was billed as a CPT 99245 (‘level 5’) office visit that included a complete history, comprehensive examination, highly complex medical decision making, even though there was no blood pressure, height, weight, pulse or breaths in the medical record. At best, the registry supports a preoperative vasectomy visit focused on CPT 99241 (‘level 1’) problem. In addition, the procedure fee includes a preoperative visit (Phillipsen et al., 2008)
  5. e) Pharmacists may fill a prescription with a specific brand of drugs rather than another that yields a bonus from the pharmaceutical company; beyond the financial implications, this could also be detrimental to the patient’s health (Rabecs, 2005)
  6. f) A physician typically bills prenatal visits under CPT code 81002 (non-automated, non-microscopic urinalysis); as a service in a prenatal or postpartum visit that was included in the code of “global maternity service” and another bill for maternal care and delivery of a baby (Phillipsen et al., 2008)
  7. g) A patient complained that he went to the office and was given “an injection.” His insurance company received a bill for outpatient surgical care (USD 360). In another case, a pediatric nurse and her collaborating doctor billed for visits to the office of the parents and siblings of a child who was brought to the office due to illness. (It seemed they found both the disease and the billing to be contagious!). Neither parent had a medical history, nor did the siblings record visits or diagnoses (Phillipsen et al., 2008), and billing for advanced life support services when essential life support was provided (Barrett, 2006)
  8. h) The fee-for-service model means that physicians seek to maximize the number of services, which means maximizing their payment (Hennig-Schmidt et al., 2011); Another case, billing amounts of drugs that are higher than those dispensed; or billing for brand name drugs when less expensive generic versions are dispensed (Barrett, 2006). The ‘rolling labs’ administer tests provided by health care providers who temporarily visit shopping centres or nursing homes; these tests are simple but are billed as expensive tests (Borca, 2001)
  9. i) A physician billed for a fetal resting test (professional services using modifier 26) performed in the labour room of a local hospital by a nurse, who communicated the results to the physician, and the patient was discharged. The physician wrote no interpretation, nor was it filed in the patient’s medical record (Phillipsen et al., 2008)
  10. j) Double/duplicate billing and reimbursement acceptance from more than one payer source for the same service (Dolan & Farmer, 2016)
  11. k) Patient was admitted on January 22, 2016, and discharged on January 24 of the same year, with a diagnosis of tuberculosis and liver cirrhosis; the patient was readmitted on January 27, 2016, and discharged on January 29 of that year with the same diagnosis. Consequently, this case is classified as suspicious (Palutturi et al., 2019)
  12. l) Many patients have been treated not according to their class I or class II coverage. Therefore, the patient is treated at a lower level (Palutturi et al., 2019)
  13. m) Billing for drugs, procedures or services previously planned but later cancelled is rare, but possible fraud of this claim (Palutturi et al., 2019)
  14. n) A patient can make claims based on a diagnosis that is not real (Ogunbanjo & van Bogaert, 2014)
  15. o) One person obtained blank prescriptions from an office and then scanned them into a computer along with a genuine doctor’s signature, then used the prescriptions to generate high-cost drugs (Mundy & Chadwick, 2002)
  16. p) A Covington, Louisiana, couple and their company pleaded guilty to their roles in a scheme to create, market, and operate a fraudulent medical reimbursement program that defrauded the IRS and program participants out of more than $48 million (USAO-EDLA, 2019)
  17. q) Insured consumers can take advantage of an accident or illness by exaggerating the amount of the loss claimed or by filing fictitious claims (Ribeiro et al., 2020)
  18. r) A person without health coverage assumes a person’s identity with insurance coverage to obtain services, consultations, procedures, diagnostic support exams (Plomp & Grijpink, 2011)
  19. s) A patient can easily visit multiple doctors for prescriptions (often multiple times) (Thornton et al., 2015)
  20. t) Falsify employment/eligibility records to obtain a lower premium rate (Liu & Vasarhelyi, 2013)
  21. u) Three examples: i) An insurance agent, try to sell insurance directly to a person; typically, only the employer can contract. ii) the plan is not licensed in your state, and the agent (falsely) assures you that federal ERISA law exempts the plan from state licensing. iii) the plan looks like insurance, but the agent avoids calling it “insurance” and instead uses evasive terms like “benefits” (Thornton et al., 2015)
  22. v) A third-party administrator who processes claims on behalf of Medicare signed an integrity agreement with the Department of Justice in response to a number of allegations, including the fact that he made incorrect payments for claim filings (Liu & Vasarhelyi, 2013)
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Health & Justice

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