phantom billing in healthcare

J. Crim. Among the most relevant manifestations perpetuated by the provider are phantom billing, falsification of documents, and overutilization of services; the subscribers are identity fraud, misrepresentation of coverage and alteration of documents; and those perpetrated by the insurance company are false declarations of benefits and falsification of reimbursements. 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. South African Family Practice, 56(1), S10S13. Likewise, another bias can be attributed to the limited search,that the range from January 1, 2006, to July 31, 2020, which itis justified by fraud penalty rules were givenstarting 2006. European Management Review, 12(3), 113147. Prevention not cure in tackling healthcare fraud. Likewise, the high deductibles and coinsurance, supported by an applied study, confirm the increase to the HIF (Lammers & Schiller, 2010). https://doi.org/10.1086/324674. Patient Billing: The medical provider needs a patient to go along with the scam. https://doi.org/10.3928/00485713-21040707-08. https://doi.org/10.1093/bjc/azn001. Pickett, K. S., & Pickett, J. M. (2002). Timofeyev, Y., & Busalaeva, T. (2019). 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. Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find, COVID-19 Is Far More Lethal, Damaging Than Flu, Data Shows, 2023. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Finally, we included 67 studies (Fig. A health librarian reviewed the search strategy. Potential for fraud of health service claims to BPJS health at Tenriawaru public hospital, bone regency, Indonesia. Optometry - Journal of the American Optometric Association, 82(5), 318321. https://doi.org/10.1016/S0140-6736(19)32527-9. 4. (2011). Gaitonde, R., Oxman, A. D., Okebukola, P. O., & Rada, G. (2016). Travaille, P., Mller, R. M., Thornton, D., & Van Hillegersberg, J. Phantom billing is a medical billing fraud involving billing for a non-existent patient or service. https://doi.org/10.2471/BLT.11.021211. Medical fraud can be classified into 4 categories: Phantom billing; Inflated billing; Upcoding; Excessive services; Phantom Billing . (2019). John Wiley & Sons. It is also highly susceptible to fraud. https://doi.org/10.15171/ijhpm.2015.196. Kumar, R., Rangarajan, K., & Ranganathan, N. (2011). Common patterns of corporate dermatology billing abuses in Medicare data sets. USAO-EDLA, Louisiana Couple and Their Business Plead Guilty To Operating Sham Medical Reimbursement Account Program That Defrauded the IRS and Program Participants Out Of Over $48 Million, 2019. https://www.justice.gov/usao-edla/pr/louisiana-couple-and-their-business-plead-guilty-operating-sham-medical-reimbursement (Accessed 20 Sept 2020). A healthcare provider who submitted claims for power wheelchairs his patients neither needed nor received; A physician who was found to have billed the federal government for hundreds of fillings and root canals, apparently performed on patients who had no teeth to even treat; and. . Obama health care for all Americans: Practical implications. Effectiveness, Efficiency, And Promptness Of Claims Handling Process In The Nigerian Insurance Industry. Lee, J., Shin, H., & Cho, S. (Jul. https://doi.org/10.1108/IJQSS-02-2017-0016. The multifactorial nature of HIF is evident, as well as the particular characteristics of its manifestations, which are subject to its definition and may differ from one country to another according to its regulatory framework and the scope of health coverage provided. Corruption and fraud are embedded in health systems (HS), and theyare motivated by abuse of power and dishonesty (Garca, 2019) that harm the user population, generating economic and even human losses (World Bank, 2018). Transparency International, Definition fraud, 2017. https://www.transparency.org/glossary/term/fraud (Accessed 12 Sept 2020). Phantom billing means charging for services never rendered Each code represents a specific procedure or service performed for patients. Fraud Spotlight: Phantom Billing & Services Not Rendered Schemes Liou, F.-M., Tang, Y.-C., & Chen, J.-Y. In this sense, our research questions seek to examine and clarify the definition used in the literature on HIF and show how this theoretical definition becomes tangible and shown in reality through the manifestation. Because taxpayers are the ones who pay for these programs, the population as a whole is also affected when fraudulent claims produce higher healthcare costs for everyone. Health Care Fraud FBI Sparrow, M. K. (2008). https://doi.org/10.1016/j.eswa.2007.02.038. (2015). IDA, 24(1), 141161. Health care fraud and abuse: Market change, social norms, and the trust reposed in the workmen. Villegas-Ortega, J., Bellido-Boza, L. & Mauricio, D. Fourteen years of manifestations and factors of health insurance fraud, 20062020: a scoping review. Combating corruption. The HIF mainly affects developing countries with fewer resources (Perez & Wing, 2019), weakened health systems and a lack of quality, causing significant losts and inefficiencies (Kruk et al., 2018). In the next session, we analyze the studies according to the quality methodology proposed in this work to specify our findings in greater detail. L. It involves charging for services that are not performed. Goel, R. K. (2020). S. Barrett, Insurance fraud and abuse: A very serious problem, Ouackuiatch, 2006. The results of this study may have important implications, as we seek to implement effective interventions that to date have eluded us. Financial Executive, 23(6). Mundy, D., & Chadwick, D. W. (2002). An applied study confirms a strong relationship between the provider and the insurer and that they increase the probability of fraud (Lin et al., 2008), and a theoretical study confirms this statement (Bayerstadler et al., 2016). Journal of Financial Crime, 23(4), 678699. Phantom billing is a type of health care fraud that involves submitting false or inflated claims to Medicare/Medicaid for services or supplies that were never provided, were not necessary or were more expensive than what was actually delivered. For the presentation of the factors related to the HIF, we considered the macroenvironment categories if the factors are motivated by external influences (Lesch & Baker, 2013); mesoenvironment, if the factors are inspired by the context of the organizations; microenvironment, if the factors are associated with demographic and individual characteristics; and the collaborative environment. The most frequently studied manifestations are related to the provider, like ghost claims, the manipulation of documents and unnecessary care, where deception and intentional misrepresentation are the most evident. Hospital Inpatient Fraud Fraud matrix: A morphological and analysis-based classification and taxonomy of fraud. (2011). Li, J., Huang, K.-Y., Jin, J., & Shi, J. https://doi.org/10.1108/IJCMA-08-2015-0049. A fraud resilient medical insurance claim System. What is Healthcare Fraud? 5 Common Medical Billing Fraud Mistakes Levi, M., & Burrows, J. Health Policy, 95(1), 4149. Laboratoriums Medizin, 45(1), e3e7. On the other hand, the infrastructure (Brooks et al., 2012), the complexity of the health systems (Vian et al., 2012) (Faux et al., 2019) lose influence in favour of increasing the HIF. Categorizing and Describing the Types of Fraud in Healthcare (2020). Estimates vary, b. Bayesian multinomial latent variable modeling for fraud and abuse detection in health insurance. Massi, M. C., Ieva, F., & Lettieri, E. (2020). Healthcare companies commit phantom billing fraud when submitting claims for services not actually performed. CESifo Economic Studies, 63(1), 123. 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. https://doi.org/10.1016/j.cmpb.2011.09.003. From this analysis, we propose the following definition: Health insurance fraud is an act of deception or intentional misrepresentation to obtain illegal benefits concerning the coverage provided by a health insurance company. The FCA is the primary weapon used to fight fraud against the U.S. government, and many states havesimilar lawsto protect themselves against fraud. Inteligencia administrativa para abordar problemas malditos? It is illegal, and some definitions describe it as a criminal act or severe federal crime. In 2021, there were 831 new criminal healthcare fraud investigations 805 new civil healthcare fraud investigations With such high numbers of cases and no end seeming to be in sight, how can you avoid becoming a healthcare fraud statistic? Also,the influence of diagnoses confirms an applied result that encourages HIF (Liou et al., 2008). B. The effects of class rarity on the evaluation of supervised healthcare fraud detection models. . Complete search strategy and characteristics of the included studies. On the other hand, if we analyzed the category of medium quality, culture contributes to an increase in the fraud supported by an applied study (Zourrig et al., 2018), even when a theoretical study shows that it decreases the HIF. 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). International Journal of Health Policy and Management, 5(3), 165172. Categorizing and describing the types of fraud in healthcare. https://doi.org/10.1057/sj.2011.7. Similarly, under the qui tam provisions 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. volume9, Articlenumber:26 (2021) https://doi.org/10.1177/097206341101300302. Liu, Q., & Vasarhelyi, M. (2013). Phantom billing. The HIS also identifies an institution or programme that helps pay for medical expenses, either through privately acquired health insurance, social insurance or a social welfare programme funded by the government (Brooks et al., 2017). Fraud in the HS is often included in the discussion of corruption since these practices generally involve abuse of power (Vian, 2020). However, legal frameworks refer to fraud as a conceptual swamp (Green, 2007). Under thefederal False Claims Act (FCA), the U.S. government investigates healthcare providers who defraud the government. This file contains details of the four quality assessment factors for each of the 67 studies included in the analysis. Inflated bills occur when patients are billed more than a procedure should have cost, for extra equipment not actually used or for the same cost twice. Systematic review of the international literature on corruption in the health care system. Qui tam suitsare filedunder sealto protect the reporting individuals anonymity and preserve the integrity of the investigation. DM conceptualised the study and designed the scoping review, planned the search strategies, performed the screening, extraction of the studies, examined and assessed the quality of the articles, analysed the data, wrote the first draft of the review article, revised the manuscript, approved the final version of the manuscript and accepts responsibility for the entire content of the article. Technology curtails health care fraud. Another theoretical study confirms this claim (Hillerman et al., 2017). Journal Risk and Insurance, 82(4), 921946. In Proceedings of the thirtieth AAAI conference on artificial intelligence, (pp. Common Billing Errors That Land Medical Providers On The Government's The multifactorial nature of HIF and the characteristics of its manifestations depend on its definition; Identifying the influence of the factors will support subsequent attempts to combat HIF. The Most costly billing practices ever. The possible score generated by this tool varies between 4 (qualitative design, sampling and collection of unexplained data, and narrative analysis) and 13 (quantitative experimental design, random sampling, explained data collection and inferential statistics) (Olsen & Baisch, 2014; Pfaff et al., 2014). American Journal of Health Economics, 5(4), 481508 Available: https://EconPapers.repec.org/RePEc:tpr:amjhec:v:5:y:2019:i:4:p:481-508. Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to Do about It Book Terry L. Leap 2011 Published by: Cornell University Press Series: The culture and politics of health care work View Buy This Book in Print summary LBB performed the formal analysis, assessed the quality of the articles and the writing of the first original draft, accepted the final version and accepted responsibility for the entire content of the article. Project MUSE - Phantom Billing, Fake Prescriptions, and the High Cost 2. Kerschbamer, R., & Sutter, M. (2017). However, when the evidence, they often argue deficiencies in supplies, medical materials, stock, in the number of professionals or sustain that the equipment is damaged or under maintenance, thereby circumventing the true intentions thatthey have as perpetrators. What is Phantom Billing? - Brown, LLC statement and Health insurance fraud (HIF) is a substantive component of the HS crisis (Manchikanti & Hirsch, 2009). Detecting medical prescriptions suspected of fraud using an unsupervised data mining algorithm. June 10, 2016: Patients Can Get Dinged in Phantom Billing Scam Unsuspecting patients can lose valuable benefits when medical providers charge for unnecessary procedures. . To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The evaluation of trustworthiness to identify health insurance fraud in dentistry. (2016). Evidence on the Intended and Unintended Consequences of Expanded Enforcement. Based on our results, we recommend that future investigations that explore HIF look for the relationships between the factors and their manifestations. Abdallah, A., Maarof, M. A., & Zainal, A. How do I fight Medicare/Medicaid fraud charges for phantom billing Excel matrix. An integrative review of the factors influencing new graduate nurse engagement in interprofessional collaboration. Privacy A medical treatment based scoring model to detect abusive institutions. All this, supported by theoretical studies. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. L. & Criminology, 96, 727. https://doi.org/10.1016/j.nurpra.2008.09.006. The Employee Retirement Income Security Act of 1974, International Association of Insurance Supervisors, Internal Revenue Service, the federal government of the United States, National Health Care Anti-Fraud Association. Google Scholar. https://doi.org/10.1002/pad.1607. Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches. Identifying the factors and their influence will allow any subsequent attempt to propose practices that mitigate HIF. While there is no standard on how to classify fraud, a 2015 study on fraud in medicine identified 18 fraud types, including providing unnecessary care and phantom billing (a process in which a. International Journal of Conflict Management, 27(3), 353378. (2011). Universal health coverage: Moving towards better health: Action framework for the Western Pacific region. The False Claims Act provides financial incentives for individuals who report fraud to the government, permitting whistleblowers to share in the governments monetary recovery. Phantom Billing: Can you spot it in your claims? - LinkedIn Electronic Fraud Detection in the US Medicaid Healthcare Program: Lessons Learned from other Industries. Furthermore, with mixed results, we found that culture maintains the results concerning HIF (Ribeiro et al., 2020; Zourrig et al., 2018). https://doi.org/10.1007/s10729-015-9317-3. Tovino, S. A. https://doi.org/10.1002/9781119203636. Tricco, A. C., Lillie, E., Zarin, W., OBrien, K. K., Colquhoun, H., Levac, D., Straus, S. E. (2018). Brugu, Q., Canal, R., & Paya, P. (2015). The Journal for Nurse Practitioners, 12(2), 8894. (2007). A survey on the state of healthcare upcoding fraud analysis and detection. Finally, the values that regulate human behaviour, such as ethics and morals, determine fraud. https://doi.org/10.35940/ijitee.K1578.0881119. Elements of the definition of health insurance fraud, its factors and manifestations. https://doi.org/10.1108/JFC-11-2015-0062. Yusuf, T. O., & Ajemunigbohun, S. S. (2015). The Lancet Global Health, 6(11), e1196e1252. Healthcare providers are not always the sole offenders and sometimes solicit patients who involve themselves in Medicare fraud schemes in exchange for monetary kickbacks. Likewise, the error is not intentional, so it does not constitute fraud (Brooks et al., 2017). https://doi.org/10.1257/aer.104.9.2900. Electronic health records: An audit and internal control guide. The individuals involved with the phantom corporations will then recruit patients by offering them an incentive in exchange for allowing their insurance to be billed. Bauder, R. A., & Khoshgoftaar, T. M. (2020). Filing claims for medical services that were never given ("phantom billing") Providing wrong details such as identities, dates and descriptions of services Modifying medical records Wrongly. Dolan, C. M., & Farmer, L. J. Lesch, W. C., & Baker, B. R. (2013). 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. For a honest maghreb care system. Yusuf, T. O. We limited our search from January 1, 2006, to July 31, 2020, taking into account that theU.S.Department of Health and Human Services issued in 2006, the final rule that establishes civil monetary sanctions, procedures for investigations and hearings, for violating the Health Information Portability and Privacy Act (Tovino, n.d.). Joudaki, H., et al. Should We Do More to Police Medicaid Fraud? Finally, the medical record supported by a theoretical study (Smith et al., 2013) confirms a decrease in HIF. A scoring model to detect abusive billing patterns in health insurance claims. https://doi.org/10.1016/j.jocs.2017.02.007. Your privacy choices/Manage cookies we use in the preference centre. https://doi.org/10.1186/s40352-021-00149-3, DOI: https://doi.org/10.1186/s40352-021-00149-3.
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