Having sat on the front lines of healthcare services for years, Ileana Hernandez understands first-hand the potential risks associated with healthcare fraud. Ileana Hernandez of Manatt has been instrumental in litigating some of the largest cases in this area.
We spoke with Hernandez about how deep fraud can go within the healthcare system and what steps people may take to prevent it from happening to them.
What are the most common healthcare fraud schemes? What are some of their goals?
Hernandez: Fraudulent activity within healthcare can vary from insurance billing schemes to kickbacks for referrals, but money is at the heart of it all. There are standard types of fraud that we’ve seen time after time: billing for services not rendered (i.e., phantom billing), double-billing, kickbacks, and upcoding claims (i.e., billing for a more complicated or expensive service than what was performed). With regards to gaining referrals, everything from buying prescriptions to bending the truth about the condition of a patient is fraudulent activity – it is all about getting another person to give you business.
Do individuals commit these crimes, or are they more widespread?
Hernandez: It really depends on the type of fraud involved. At its roots, insurance billing schemes are typically perpetrated by an individual. However, the schemes are more widespread when it comes to kickbacks and other means of gaining referrals. As mentioned above, either one person goes to great lengths to convince another person to give them business, or a whole team of individuals is involved in the process. There are also times when an individual commits fraud by billing for services they never even rendered (phantom billing), which makes it difficult to pinpoint individual culprits.
How do the individuals perpetrating these crimes benefit from them?
Hernandez: In most cases, the goal is to gain business or money – either by billing for services that have not been rendered at all or by illegally obtaining a referral and getting paid for successfully serving a patient they were referred to. With regards to phantom billing, though, the incentives are not as clear. For example, individuals may attempt to pad their hours regularly to make extra money, but this is rare.
How do healthcare providers figure into these crimes?
Hernandez: Healthcare providers can be victims or perpetrators of fraud depending on the crime under discussion. For example, if a hospital is involved in phantom billing, they are the victims. However, when it comes to kickbacks and other forms of gaining referrals illegally, the healthcare providers become fraud perpetrators.
What can people do to prevent these crimes from occurring?
Hernandez: Fraud and abuse within healthcare have been going on for years and will continue to do so in the future. These crimes always seem to be one step ahead of prevention efforts, but there are ways people can take action and prevent fraudulent activity from occurring to them directly. For example, patients should double-check their medical bills when they receive them to ensure they were billed for the services rendered – not a similar service that was already paid for. Furthermore, patients should file a complaint with their insurance company or state healthcare program if they believe they are the victim of fraud. Finally, always ask questions when receiving care to ensure what you are being billed for is correct and you understand precisely what will be performed – this will reduce instances of double billing.