Healthcare fraud serves as a blanket term for numerous actions and situations in which a healthcare professional or provider commits fraudulent acts. Some of these acts get more press coverage than others, such as the illegal selling of prescription drugs or falsifying medical records.
Others get less attention, such as the provision of unnecessary medical services. Exactly what is this form of fraud and how does it manifest in a healthcare setting?
Charging for unnecessary ambulance rides
KETK discusses a case in which an ambulance operator faced fraud charges for providing an unnecessary service. In specific, this individual billed Medicare and Medicaid for ambulance services that they provided to patients even if the patients did not need them. Regarding ambulance use, ambulance providers only bill in the event of a demonstrated need for an ambulance, such as the beneficiary’s medical condition requiring ambulance transportation.
But unnecessary services can apply to all services that medical professionals offer. This can include medications and prescriptions, suggestions for operations, medical devices, or even physical therapy. Essentially, anything you charge a patient for by framing it as a necessity when that is not the cause is an act of fraud.
Understanding medical necessity
You must then understand what medical necessity is. By definition, a medical necessity is a service or procedure needed to diagnose or treat an injury or illness. Providers often have their own definition, so it is important to have a strong familiarity with each individual set. After all, even unintentional fraud often gets treated with the same severity and potential penalties under the eye of the law, which can have severe repercussions.