Health Care Fraud Brochure

What is Health Care Fraud?

The FBI has a continuing responsibility to respond to allegations or development of information within the FBI’s jurisdiction involving attempts to defraud the public or private health care systems in the United States. Health care fraud can take many forms but the overlying fact is that public health care insurers - such as Medicare and Medicaid - or private insurers can be scammed into overpaying for medical services or products. As a result, millions of people who contribute to these programs are forced to pay increasingly higher fees.

Fraudulent activities are becoming increasingly complex and can be perpetrated by any health care provider, ranging from a single physician medical practice to a major health care corporation.

The FBI continues to strengthen its efforts to combat health care fraud by creating national initiatives geared towards addressing specific types of fraudulent activity.  Some areas of fraud include:

·        Durable medical equipment

·        Home health care

·        Pain management

·        Chiropractic care

·        Laboratories

·        Infusion therapy

·        Auto accidents

·        Outpatient surgery

Health Care Fraud investigations are among the highest priority investigations within the FBI's White Collar Crime Program.  With consumers spending over $1 trillion in private sector health care alone, the FBI’s investigations in this area are critical.    

Types of Health Care Fraud

Health Care Fraud is carried out by many segments of the health care system using various methods.  Some of the most prevalent schemes include:

Billing for Products or Services not Rendered – Can involve any situation with an incorrect billing statement and can include situations where:

·        No medical service of any kind was rendered

·        The service was not rendered as described in the claim for payment

·        The service was previously billed and the claim had been paid

This can also involve a provider submitting a billing statement using procedure codes that result in higher payments than the code for the actual product or service (“upcoding”). For example:

·        A routine, follow-up doctor's office visit being billed as an initial or comprehensive office visit

·        Group therapy being billed as individual therapy

·        30-minute sessions being billed as 50+ minute sessions

·        Supplier delivers a manually propelled wheelchair, but bills the patient's health insurance plan for a motorized version

Medically Unnecessary Services – Providing products or services which are beyond the patient’s needs. For example:

·        Daily medical office visits conducted and billed for when monthly office visits would be more than adequate

·        Ordering an electrocardiogram (EKG) test when the patient has no conditions, complaints, or factors which would necessitate the test

·        A medical supply company billing for 30 wound care kits per week for a nursing home patient who requires a change of dressings once per day

“Kickbacks” – Accepting money or something of value in exchange for the referral of a patient for health care services that may be paid for by Medicare or Medicaid. Kickbacks can be seen in various forms other than cash including jewelry, free paid vacations, or other valuable items. For example:

·        When a laboratory owner pays a doctor a fee for each Medicare patient the doctor sends to the laboratory for testing

Duplicate Claims – A duplicate claim usually involves a certain item or service for which two claims are filed.  In this scheme, the provider usually changes a portion (most often the date of service) of the claim so that the health insurer will not realize that the claim is a duplicate.   

Applicable Federal Statutes 

Numerous federal statutes are utilized in health care fraud investigations including bribery, “kickbacks,” false claims, false statements, mail and wire fraud, obstruction of justice, money laundering, racketeering, theft and embezzlement, tax crimes, and conspiracy.  The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides strict guidelines for the security of medical information. 

The FBI wants your help

Many successful health care fraud investigations were initiated based simply on a “tip” or information received by individuals who may be aware of, or witness to, some form of wrongdoing.

If you would like to report information regarding possible health care fraud or to obtain more information, please contact the Denver Division of the FBI.

Contact:        Matthew McPhillips

                        Supervisory Special Agent

Address:       Federal Bureau of Investigation (FBI)

Denver Division

                        1961 Stout Street

                        18^th Floor

Denver, Colorado 80294

Telephone:  303.629.7171

Internet:        www.fbi.gov

                        http://denver.fbi.gov

                        *Potential fraud information may also be reported through the Internet.

For a printable tri-fold form of this brochure in Adobe PDF format please click here.