Have you heard about the story of Philip Esformes?
This story revolves around healthcare fraud and prosecutorial misconduct. Mr. Esformes was wrongfully accused of healthcare fraud, and during the case, the prosecutors continually violated his rights.
Sadly, improper and unethical healthcare fraudulence cases like this occur more often that we would like to think. They can impact the lives of innocent individuals like Mr. Esformes, which is why it’s important to spread awareness about the consequences of wrongful healthcare fraud claims.
In this article, we’re not going to focus on Mr. Esformes’ story in particular. Instead, we’re going to take a look at healthcare fraud as a whole, including what it is and its consequences.
What is Healthcare Fraud?
Healthcare fraud refers to a crime in which a healthcare claim is filed dishonestly. When an individual or organization is committing healthcare fraud, they can illegally receive large payments. They defraud a healthcare provider, healthcare insurer, or health program.
In total, healthcare fraud leads to financial losses amounting to almost $60 billion every single year. Healthcare fraud isn’t confined to just one area, either. There are several different kinds of healthcare fraud, and every kind of healthcare worker, practitioner, or insurance employee can commit this type of fraud.
What Are the Consequences of Healthcare Fraud?
Healthcare fraud is a serious issue, not only because it costs healthcare providers and insurers billions of dollars every year but because it’s illegal. This type of fraud is a crime and has serious consequences for the perpetrators.
When fraudulent healthcare claims are filed, other customers are the ones who end up paying for them. Statistics suggest that around one-tenth of every dollar that customers spend on healthcare (whether it’s for medical treatment or health insurance) goes toward paying fraudulent claims.
When significant fraudulent claims are filed, the healthcare provider or insurer might increase their premiums to make up for the associated financial loss. So, every innocent, law-abiding healthcare customer ends up paying more than they previously were for the same level of treatment.
Healthcare fraud can also place mistrust in customers. They may start to feel frustrated with their healthcare provider or insurer, and as a result, the healthcare company’s credibility takes a hit.
What Are the Types of Healthcare Fraud?
There are two main categories that fall under the healthcare fraud umbrella – practitioner fraud and customer fraud.
Practitioner fraud
A practitioner or healthcare employee may commit fraud in the following ways:
• Prescribing medications that aren’t needed to resell them on the black market for a higher cost
• Prescribing medications that aren’t covered by the patient’s healthcare policy
• Filing repeated claims for the same issue
• Filing claims for healthcare services that were not provided (this is known as phantom billing)
• Wrongfully editing medical records
• Purposefully adding medical treatments or procedures that are not required to increase the amount of the claim
• Purposefully stating the wrong medication or service details
• Wrongfully billing for a medical service that is not covered by the healthcare provider or insurance policy
Customer fraud
A healthcare customer may commit fraud by:
• Selling their prescription drugs to make a profit
• Providing the wrong personal details when signing up for a health insurance policy
• Claiming for transportation that was not used for access to healthcare services
• Claiming against a healthcare provider for treatments that they did not receive.
• Filing a healthcare claim using somebody else’s details
Healthcare fraud is illegal and has serious legal consequences. Luckily, Philip Esformes was able to prove his innocence after the wrongful fraud accusations against him. Being aware of your legal healthcare-related rights and responsibilities, just as Mr. Esformes was, will ensure that you know exactly what to do if you are wrongfully accused of fraud.
