Signs Of Fraud In The Health Sector [sponsored]

April 6, 2020

Health care fraud is usually committed by a small minority of health care providers and organized crime groups that waste healthcare tax dollars. According to the National Health Care Anti-Fraud Association (NHCAA), the financial loss estimates due to healthcare are tens of billions of dollars annually. 

That's why everybody has a social responsibility to report any signs of healthcare fraud. So, how do you know if healthcare fraud is happening?

In this post, you'll learn how to determine the signs of fraud in the healthcare sector so that you can make the best decision and course of action.

Double Billing

Every test that a doctor performs has a corresponding billing code for medical transcription and health insurance claim purposes, which are referred to as Current Procedural Terminology (CPT) codes. Each code has a dollar amount based on health insurance. The doctor or healthcare organization keeps track of everything, most especially CPT codes, and they’re submitted to the insurance company as claims. 

One type of healthcare fraud involves manipulating these codes in the form of double billing, also known as duplication billing. This indicates a serious problem.  

Here are the important things you should be aware of when it comes to double billing:

  • It happens when a healthcare organization, clinic or hospital, bills the patient for the same testing, procedure, or treatment on more than one occasion. 

  • Double billing also includes billing a patient for the wrong service and patient services or procedures that never took place.

  • Double billing also occurs when Medicaid, Medicare, or another private insurance company bill the patient right away. 

  • Doctors who don't check if the patient was already billed for a procedure or charges patient procedure more than once is also indicative of healthcare fraud. 

For protection, whistleblowers can report this type of healthcare fraud and obtain Patient Assistance Programs Fraud. 

healthcare fraud

Inadequate Care and Prescription Medication Fraud 

The Centers for Disease Control and Prevention (CDC) says that about 15,000 people die due to prescription medicine overdoses, and 1.2 million people visit the emergency room for drug overdose every year. That's why proper prescription and medication dispensing are important at all times. 

Pharmaceutical fraud or prescription fraud happens when someone obtains medications using forged prescriptions and other forms of deception. How is this possible? The patient or doctor might be involved.

Here are some examples of red flags indicating possible prescription medication fraud:

  • The patient has prescriptions from different doctors, including a combination of prescription painkillers, tranquilizers, and opioids.

  • A patient who frequently travels to pharmacies that are far from their home

  • A patient who runs through medication too quickly and seeks a refill after two weeks for a supposedly one month supply

  • Doctors who write a suspiciously large number of prescriptions for narcotic painkillers, tranquilizers, and opioids to patients without pain problems or medical diagnosis. 

Incorrect Healthcare Information

Healthcare professionals who attempt to commit fraud may use the healthcare information of a patient for a purpose other than the intended purpose. Incorrect date, location, patient services, and healthcare provider information indicated on the medical paperwork or billing is another example of a probable sign of healthcare fraud. 

That's why all medical paperwork, including benefit paperwork, must be up-to-date and accurate. Otherwise, you can be suspected of healthcare fraud.

Waiving of Co-payments or Deductibles

Routinely waiving a patient’s insurance responsibility violates the contract between the healthcare provider and the private insurance company. If the doctor cannot present evidence that the patient’s responsibility was already collected, the insurance company can demand a refund. 

When it comes to Medicaid, Medicare, and Tricare patients, the same laws apply, with greater risk if the physician won't comply. The doctor can be charged with healthcare fraud, which raises potential liabilities to the Federal False Claims Act, the Federal Anti-Kickback Statute, and state laws.

Physicians cannot always forgive the debt, and waiving deductibles or co-payment is only reserved for patients suffering from a financial crisis. If a healthcare provider advertises “insurance-only billing,” “no out-of-pocket costs,” or routinely waives cost-sharing forms, including co-pays and deductibles, insurance abuse and fraud are likely being committed.


Fraudulent activities in the health sector are very alarming, which results in billions of dollars going to certain people's pockets instead of being used for improving and providing public healthcare services. 

Inaccurate billing, incorrect patient information, double billing, and prescription medication mistakes are just some of the signs of healthcare fraud. If you suspect any of these, it’s within your duty to report these fraudulent acts to a patient assistance program fraud lawyer.




CP Wire

Submit an article to cafepharma's CP Wire. Click here to find out more.

current feelings about your job

Please rate how you feel about your job this moment. 1 = "I hate my job" and 7 = "I love my job"
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Fill in the blank.