Describe two examples of fraud that can be committed by a physician.

Question

What will be an ideal response?

Answer 1

Phantom treatment (or fee-for-service reimbursement): situations where a provider bills insurance
companies for services they never provided—ii. Substitute providers occurs when the medical services
were performed by an employee who is not authorized to perform the services—iii. Upcoding (or
upgrading): when providers bill for services that are more expensive than the services that they provided
—iv. The provision of unnecessary services occurs when health care providers perform tests or
procedures that were not needed and bill the insurance company—v. Misrepresenting services: providers
describe the service differently on paperwork in an effort to receive payment for services—vi. Falsifying
records: providers change medical paperwork in an effort to be reimbursed by the insurance company—
vii. Overcharging patients: situations where providers charge patients more than what is allowed by
regulations—viii. Unbundling: instances when the provider bills separately for tests and procedures that
are supposed to billed simultaneously—ix. Pingponging: situations where patients are unnecessarily
referred to other providers—x. Ganging: instances when providers bill for multiple family members when
they only treated a single family member—xi. Kickbacks: when providers refer patients to other providers
in exchange for some type of reimbursement from the other provider—xii. Co-pay waivers: when
providers waive the patient’s co-pay, yet bill the insurance provider for the visit—xiii. Medical
snowballing: when providers bill for several services, when a single service was provided