Question

. Of the following practices, which constitutes fraud? • Billing for services not provided. • Billing for services not covered under a patient’s health insurance. • Unbundling; that is, billing separately for each stage of a procedure. • A licensed health care practitioner allows an unlicensed person to bill an insurer under his name. • A medical facility waives deductibles and copayments.

Answer 1

Practices that constitutes fraud include :

1.Billing for services and procedure that are not actually provided to the patient

2.unbundling; that is, billing separately for a procedure, instead of using a single code that covers the entire procedure

3.A licensed health care practitioner allows an unlicensed person to bill an insurer under his name.

EXPLANATION :

Billing for services not covered under a patient's health insurance. This may not be fraudulent if the provider informs the patient of the covered services and obtains his consent before billing. However, it may be fraudulent if the provider misrepresents the services as covered or necessary, or bills them under a different code that is covered.

A medical facility waives deductibles and copayments. this practice may not be fraudulent if the power waives them a charitable reasons or based on the patient's financial hardship. However, it may be fraudulent if the provider waives them routinely or selectively, or inflates the charges to compensate for the waived amounts.