NCJ Number
139194
Journal
FBI Law Enforcement Bulletin Volume: 61 Issue: 10 Dated: (October 1992) Pages: 17-20
Date Published
1992
Length
4 pages
Annotation
After identifying the six main schemes in Medicaid fraud, this article describes Tennessee's efforts to counter these crimes and identifies the problems encountered in Medicaid fraud investigations.
Abstract
The six primary health care fraud schemes are upcoding, phantom billing, billing for unnecessary services, double billing, unbundling, and giving or receiving kickbacks. Upcoding occurs when health care providers bill for a more expensive service than was actually provided; phantom billing occurs when health care providers present bills for services not performed; billing for unnecessary services involves charges for services and equipment that have no medical value; double billing means the submission of bills for the same services twice; unbundling consists of billing Medicaid separately, as if performed on different days, for procedures performed during one operation; and under kickbacks various health care agents give kickbacks to physicians who recommend their businesses to patients. To counter these schemes, States should form special units to address these crimes, such as the Tennessee Bureau of Investigation's Health Care Fraud Unit. This unit is trained in types of health care fraud, regulations that govern the Medicaid program, and investigative techniques for various kinds of medical fraud. Before initiating a case, investigators should be alert to any special investigative problems they may encounter. Investigative problems are most likely to arise in rural areas where undercover work is made difficult by communities' tendency to be suspicious of strangers and the cultivation of witnesses is made difficult by residents' desire to protect their scarce medical professionals. 1 note