TYPES OF MEDICARE FRAUD
FALSE BILLINGS FOR SERVICES OR PRODUCTS NEVER PROVIDED
Such conduct typically involves billing Medicare for doctors visits or hospital stays that never occurred, or for treatments, tests that were never provided.
BILLING FOR UNNECESSARY SERVICES
Such conduct typically involves ordering unneccesary diagnostic tests, over-authorizing the length of hospitial stays, medically unnecessary transportation, treatments, pharmaceuticals, or medical equipment that are not medically necessary for the patient.
IMPROPER BILLING CODING
These situations involve conduct where a healthcare provider knowingly miscodes a claim in order for the provider to justify the provision of additional medical services that are not medically necessary. For example, "upcoding" is when a healthcare provider uses a higher-paying billing code when services with lower-paying billing codes were actually provided.
Such conduct typically includes off-label drug marketing. In these actions, pharmaceutical companies promote drugs for uses that have not been approved by the FDA. While a doctor may legally prescribe the drug for off-label use, the pharmaceutical company may not market for such off-label use. This may occur where pharmaceutical sales representatives directly market the drug to doctors for off-label use, or the pharmaceutical company offers monetary incentives to doctors for the off-label use of the drug.
It is illegal for physicians to receive financial incentives for patient referrals. When physicians are rewarded financially for referring patients to hospitals or other health care providers, it can affect their medical judgment, resulting in overutilization of services that drives up health care costs for everyone.
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