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Top Most Shocking Yet Common Healthcare Provider Fraud Activities You Should Know About!

According to the federal False Claims Act or the FCA act, healthcare frauds are the most commonly prosecuted crimes. The FCA has effectively recovered billions of dollars on taxpayers from unscrupulous, dishonest hospitals, doctors, pharmacies, and pharmaceutical companies. And hence, they are striving to create awareness of fraud in the healthcare sector.

If you suspect any fraudulent activities in the healthcare sector, you may voice your suspicions under the FCA. This provision allows private individuals the opportunity to share their information with the federal government. And they can do this in exchange for a percentage reward from an impending settlement or verdict.

Much as we like to ignore it, healthcare provider fraud is widespread and is widespread. And the value of the fraud runs into several million. One of the largest healthcare frauds in US history hit the news recently, and it is creating ripples all over. According to the HHS and the OIG, there were charges against 400 defendants in 41 federal districts. And this was for schemes worth over $1.3 billion.

Providers indulging in fraudulent practices engage in numerous several hair-raising creative schemes. This includes bribes, bribes, fake patients, and false billings to benefit from administrative loopholes in public programs. Yes, we are talking about the providers scheming Medicare and Medicaid plans. However, if you are not aware of healthcare fraud, read on to find out.

Kickback Schemes

Kickbacks are very common in the healthcare industry, and it leads to unlawful practices. That is why healthcare professionals are barred from accepting expensive gifts from others in a professional setting. This means a healthcare professional cannot accept cash, equity, or gifts from another person. Yes, this includes gifts from other doctors, healthcare facilities, medical device manufacturers, pharmaceutical companies, or anyone else who may refer patients at a certain rate.

And this is to prevent them from meeting certain criteria or quotas. It also helps prevent the prescription of certain medication, use particular medical devices, or decide that the offering can impact.

Medically Unnecessary Services

Medicaid and Medicare can reimburse your money based on procedures or expenses that are medically necessary. However, certain healthcare practitioners suggest unnecessary tests, procedures, and processes to their patients. And if you feel that the referral to be medically unnecessary and violates the federal healthcare rules, you can report the same. These referrals are unlawful, and the healthcare professional could attract legal action.

Not Charging Medicare and Medicaid Patients for Prescriptions

A popular grocery-store pharmacy offers in-store discounts to customers and does not provide them with Medicaid or Medicare coverage prices. They may charge the full government price for the same medication they gave at a discount price to the Medicare and Medicaid patients. This violated the program rules and resulted in a successful False Claims Act case against the pharmacy. Under the rules, a pharmacy charges Medicare and Medicaid patients a fair market value for the drugs.

 Nurses and Staff Performing Examinations

Under the Medicare and Medicaid billing rules, only physicians can perform certain procedures. Currently, there is an emerging trend where nurses or office staff handle regular outpatient procedures. However, they bill the government for the doctor’s time instead of the nurse, which costs the government a huge amount of money and leaves the patient’s life at risk.

When an amateur staff member is carrying out a complex medical procedure, it might not turn out well for the patient. A smart way to avoid this would be to check with your peers and review the hospital’s reputation online before you sign up for a procedure. However, if you still feel that you are experiencing the same at the doctor’s office, it is important to talk to an attorney. Taking legal action against healthcare facilities indulging in unlawful practices is the only way to stop such practices.


This is one of the common methods of defrauding the government. The upcoding procedures involve billing for services that were never rendered or billed for one service when the patient underwent a completely different procedure or service.

Like this fraudulent practice, illegal upcoding costs the federal government millions of dollars per case. And you can detect it by completely reviewing the itemized bill rather than just skimming through it!

If you see any suspicious activities that do not seem aboveboard and you may suspect that your doctor may engage in any unlawful billing practice, you may have to report the same. Always be cautious and be aware of the different fraudulent activities and report the same if need be. That’s the only way you can avoid fraudulent medical activities. And if you were to notice any fraudulent practices or suspicious activities, make it a point to report them to the authorities. That way, no one else would fall victim to the crime.

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