phantom billing in healthcare

We identified 26 studies that explained 15 factors, the most referenced factors are audit, supervision and control, with 8 studies, while 6 studies explain the general characteristics of the provider. We have proceeded to an analysis of the 47 identified factors, their corresponding influences supported by theoretical or applied contributions to increasing or decreasing the HIF (Tables3 and 4). If you are aware that your employer is committing fraud against the government and want to come forward with a claim, it is vital that you work with a law firm that has a great deal of professional experience with Medicare fraud lawsuits, and thus an extensive understanding of the complex regulatory schemes that govern such suits. Manila: WHO Regional Office for the Western Pacific. While the factors related to having an older age to be deceived (>65), place of residence (Goel, 2020), patient diagnoses, medical and surgical treatments (Liou et al., 2008), medications (Aral et al., 2012; Herland et al., 2018; Lin et al., 2008; Liou et al., 2008; Weiss et al., 2015), chronic health condition (Liou et al., 2008), and deductibles and coinsurance (Lammers & Schiller, 2010) showed influence in increasing the HIF. In this category, other factors (medical record, provider responsibility, provider internal mechanisms, internal staff evaluations, patient identification mechanisms, among others) have been shown to contribute to reducing HIF; several are theoretical or of medium or low quality. According to Brug et al., the main problem lies in contrast between the simplicity of our administrations and the complexity of the problems to be solved; the classical administrative modus operandi consists of simplifying problems by reducing themselves to a specialized field; This explains why our results show the same factor with ambivalent influence, which confirms the sensitivity of the factors (Brugu et al., 2015). Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Qui tam suits are filed under seal to protect the reporting individuals anonymity and preserve the integrity of the investigation. Excess number of services - billing unnecessary . Medical identity theft is a form of identity theft that occurs when someone fraudulently uses your health insurance information to gain illegal access to medical care services. https://doi.org/10.1016/j.jhsa.2015.05.024. Johnson, M. E., & Nagarur, N. (2016). For a better understanding, we present Table3. Finally, in two of the studies, two manifestations of fraud of the agent or insurer were identified: false declarations of benefits or services and falsification of reimbursements. Herland, M., Khoshgoftaar, T. M., & Bauder, R. A. The results obtained are intended to promote future studies that more effectively channel the interventions that prevent, detect, and provide responses to combat HIF and be a reference for decision-making in countries public health. We reviewed studies according to our objective, and we included those reviewed by peers and are indexed to international databases since they are considered validated knowledge. June 26, 2023 Whistleblower One of the most common types of health care fraud is known colloquially as "Phantom Billing" and has serious civil and criminal consequences under various state and federal statutes particularly when federal funds are involved like Medicare. https://doi.org/10.1177/097206341101300302. Ribeiro, R., Silva, B., Pimenta, C., & Poeschl, G. (2020). 4. Optimal auditing with scoring: Theory and application to insurance fraud. We analyzed 67 primary studies from January 2006 to July 2020, including definitions, manifestations, and HIF factors. Two models to investigate Medicare fraud within unsupervised databases. https://doi.org/10.1016/j.artmed.2016.12.002. Five definitions affect the term deception, which is associated with an act linked to misrepresentation and deception. Terms and Conditions, https://doi.org/10.3233/IDA-184415. Additionally, reimbursement processes and billing characteristics (Hillerman et al., 2017) confirm an increase in the HIF. Potential for fraud of health service claims to BPJS health at Tenriawaru public hospital, bone regency, Indonesia. The False Claims Act providesfinancial incentivesfor individuals who report fraud to the government, permitting whistleblowers to share in the governments monetary recovery. A factor can show both signs simultaneously (+), which means that its influence is ambivalent. However, legal frameworks refer to fraud as a conceptual swamp (Green, 2007). Computer Methods and Programs in Biomedicine, 106(1), 3746. Kacem, M., Melki, S., Nouira, S., Khelil, M., Belguith, A. S., & Abdelaziz, A. This involves the patient giving the physician his or her Medicare number and being paid to lie about receiving the phantom tests. Common Billing Errors That Land Medical Providers On The Government's Phantom billing: Billing for services not rendered, called "phantom billing," has been a well-recognized problem in claim payments long before coronavirus became a household name. Medicare fraud - Wikipedia Given the absence of a standardized definition of HIF, this scoping review could contribute to filling a gap in knowledge, providing a definition with a homogeneous language, which can dispel ambiguity and facilitate its understanding. They can be categorized in multiple ways, such as by actors: internal staff, patient, intermediary and insurer (Yusuf, 2010); and by environment: context, organization and individual (Vahdati & Yasini, 2015; Vian, 2020), or internal and external (Akomea-Frimpong et al., 2016). Although similar in some respects, they are different fraud schemes, they're often confused with each other. Kang, H., Hong, J., Lee, K., & Kim, S. (Apr. Electronic Fraud Detection in the US Medicaid Healthcare Program: Lessons Learned from other Industries. IAIS, Principios Bsicos de Seguros, Estndares, Guas y Metodologa de Evaluacin, 2011. Yusuf, T. O. Brugu, Q., Canal, R., & Paya, P. (2015). Similarly, under thequi tamprovisions of the False Claims Act, private citizens with first-hand knowledge of government fraud can, after consulting with an experienced False Claims Act attorney, file, and benefit from, lawsuits on behalf of the United States. Victorri-Vigneau, C., Larour, K., Simon, D., Pivette, J., & Jolliet, P. (2009). Inteligencia administrativa para abordar problemas malditos? A normative approach to white-collar crime. JVO and LBB currently work in a government entity, the National Superintendency of Health in Peru. (Apr. Health Care Manage Sci, 11(3), 275287. Phantom billing occurs when healthcare providers submit claims for reimbursement to the government for services or procedures they did not perform, or for higher-priced products or services than those provided to their patients. CMS categorizes fraud and program integrity issues into 4 categories: (1) mistakes resulting in administrative errors, such as incorrect billing; (2) inefficiencies causing waste, such as ordering excessive diagnostic tests; (3) bending and abuse of rules, such as upcoding claims; and (4) intentional, deceptive fraud, such as billing for service. The Most costly billing practices ever. By using this website, you agree to our https://doi.org/10.1016/j.procs.2015.08.594. Additionally,the perception of inequity and injustice supported by a theoretical study (Ribeiro et al., 2020) and the asymmetry of information supported by three applied studies (Kumar et al., 2011; Ribeiro et al., 2020; Zhou et al., 2016) confirm a decrease in fraud. However, other theoretical studies showed that the diagnoses (Sun et al., 2020) and medications reduced HIF (Haddad Soleymani et al., 2018; Sun et al., 2020; Victorri-Vigneau et al., 2009). This billing not only . Measuring the impact of fraud in the UKA conceptual and empirical journey. Liou, F.-M., Tang, Y.-C., & Chen, J.-Y. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Phantom billing. Rev., 81, 1261. https://doi.org/10.1016/j.asoc.2015.07.018. (Feb. 2014). https://doi.org/10.1136/amiajnl-2013-001714. JVO conceptualised the study and designed the scoping review, planned the search strategies, carried out the screening, extraction of the studies, examined and evaluated the quality of the articles, the data analysis, wrote the first draft of the review article, wrote the manuscript, approved the final version of the manuscript and accepts responsibility for the entire content of the article. Overbilling, Upcoding, Unbundling, & Excessive Billing Factors affecting internet frauds in private sector: A case study in cyberspace surveillance and scam monitoring agency of Iran. El caso de las comisiones interdepartamentales. https://doi.org/10.1257/aer.104.9.2900. Desperate times can call for desperate measures. In addition,the medical specialitiesand the bad economic situation confirms an increase in fraud,supported by an applied study (Shin et al., 2012). (2010). Upcoding refers to when a healthcare organization or provider delivers a particular medical service to a patient but uses a more expensive "code" when billing for the service. Wiley. A scoping review on health insurance fraud published between 2006 and 2020 was conducted in ACM, EconPapers, PubMed, ScienceDirect, Scopus, Springer and WoS. Konijn, R. M., Duivesteijn, W., Meeng, M., & Knobbe, A. Your privacy choices/Manage cookies we use in the preference centre. Two phrases that are common in the healthcare fraud world are: phantom billing and services not rendered . HIF is a problem that ranks second after violent crimes in the United States (USA) (Sparrow, 2008) and can be committed by medical providers, policyholders and health insurers (Busch, 2008). Google Scholar. To guarantee not to lose potential studies, we applied an iterative approach; we initially used the studies that met the inclusion criteria in PubMed and WoS. There are three easy ways to contact our firm for a free, confidential evaluation with one of our whistleblower attorneys: Your submission will be reviewed by a Berger Montague qui tam attorney and remain confidential. 2. Compliance in interventional pain practices. Therapies, 64(1), 2731. In unbundling, the crooked healthcare providers are experts in manipulating the codes used in the billing system of the medical services so that they can get higher reimbursements without alerting the patient. (2010). In a study conducted in the state of Florida, USA, we found statistically significant results that encourage HIF: the western region, being a woman, being white, having health insurance, predominantly Englishlanguage, having a condition sensitive to health, greater future risk of illness, healthcondition (Manocchia et al., 2012). IJPP, 8(1/2/3), 136. https://doi.org/10.1504/IJPP.2012.045878. Managerial and Decision Economics, 41(4), 520528. Universidad Nacional Mayor de San Marcos, Av. The DOJ report issued on January 14, 2021, stated that it recovered $2.2 Billion from false claims in FY 2020 of which $1.8 . This phenomenon is explained by having a culture permissive to fraud, where ethics and morals are often bypassed by economic interests, the lack of patients to report and lax legislation. The FCA is the primary weapon used to fight fraud against the U.S. government, and many states havesimilar lawsto protect themselves against fraud. https://doi.org/10.1016/j.jnca.2016.04.007. Likewise, patients who require Medicare services suffer when resources from these systems are drained, resulting in services that must be cut and patient coverage that must limited. (Sep. 2008). Fraud in sustainability departments? Corruption in global health: The open secret. To have a single definition of HIF, we have again integrated what is described in A, B, C and D, from which we obtained that Fraud is a deliberate deception to obtain unfair or illegal profits, a statement that is complemented by described in E. We specified that the absence of one of five key elements identified puts at risk the comprehensive definition of HIF. Hennig-Schmidt, H., Selten, R., & Wiesen, D. (2011). We also excluded studies with meanings ascribed to health abuse related to drugs, diseases, suicide, racism, food fraud, security, network, web, and electronics device; all of themfor being away from the health insurance environment. In 23 studies, we identified 13 manifestations of fraud by the provider; the three most common manifestations are phantom billing based on claims presented for medical services not provided, mentioned in 14 studies, the falsification of administrative or clinical documents in 10 studies and the proportion of unnecessary care in 9 studies. (2019). Springer. Healthcare fraud and phantom billing has been a very salient topic and criminal matter since the pandemic began a year ago. Park, J., Kim, M., & Yoon, S. (2016). Finally, we arrived at the following definition: Health insurance fraud is an act based on deceit or intentional misrepresentation to obtain illegal benefits concerning the coverage provided by health insurance.. Accessed 5 Sept 2020. The responsibility of the provider (Kerschbamer & Sutter, 2017), the measures of the administrative authority (Jator & Hughley, 2014), and the internal mechanisms of discipline (Myckowiak, 2009), the performance and quality evaluation system (Kerschbamer & Sutter, 2017), the commercial implication (Konijn et al., 2015), the employability and satisfaction with his work (Brooks et al., 2012), patient identification mechanisms (Jator & Hughley, 2014); they lose their influence in favour of reducing fraud, all supported by theoretical studies. Our findings identified 6 theoretical definitions, 22 manifestations (13 of the provider, 7 of the insurer and 2 of the insurer) and 47 factors categorized into macroenvironment (6), mesoenvironment (15), microenvironment (20), and collaborative (6). Healthcare fraud entails great financial and human losses; however, there is no consensus regarding its definition, nor is there an inventory of its manifestations and factors. Sheffali, S., & Deepa, D. V. (2019). The FBI has identified the following as the most common sources of billing fraud committed by medical providers: 1 (1) . https://doi.org/10.1002/pad.1607. How do I fight Medicare/Medicaid fraud charges for phantom billing (2016). A medical equipment company who submitted false claims for equipment like oxygen generators and breathing machines that was materially different from and more expensive than what patients actually received.

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