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Insurance Fraud Networks Affecting Florida Healthcare, Physicians

WILMINGTON, Delaware, June 6, 2011 /PRNewswire/ — The level at which healthcare insurance fraud operates in Florida(http://www.medicalbillersandcoders.com/0-florida-0-medical-billing.html) has shocked the National Health Care Anti-Fraud Association and The Department of Financial Services, a division of Insurance Fraud, that investigates frauds for all types of insurance. The intensity with which the frauds are planned has alarmed the investigators and given them enough reason to investigate just about any clinic’s claims.

– Physicians in Florida have paid Medicare beneficiaries to sign papers for the treatment that was not administered and use their Medicare numbers to bill Medicare

– Physicians support up-coding and un-bundling mostly for expensive drug infusion treatments for blood disorders

– Falsify medical records to show severe symptoms

– Hire specialized billing companies to bill Medicare

– Bill for deceased doctor

– Bill for doctor not available at PoS to Medicare


Consequences for physicians with such dubious intentions of course has been a sentence of ten (10) years and financial penalty depending on the level of fraud.

National Health Care Anti-Fraud Association estimates that nearly $51 billion that is approximately 3% of the healthcare industry’s expenditure in the United States is due to fraudulent activities. However, it is difficult to gauge the extent of fraud but it is estimated that annually $115 billion is drained out of the system.

Shocking it is, but medical fraud is highly prevalent in Florida; physicians gain financially and most patients feel they are not affected as insurance takes care of the expenses even if it is fraudulent. Unfortunately they do not realize that because of such practices insurance companies hike premiums that increase the cost of healthcare.

There is also a certain section of physicians who believe in billing only for the services provided and at appropriate cost ethically, but these physicians are unaware of the billing and coding practices. Such physician practices are dependent on billers and coders who may or may not fully understand the implications of incorrect or fraudulent billing.

Incorrect or fraudulent practices over a period of time can land a physician’s practice under the scanner of Recovery Audit Contractor (RACs). Suspicious claims are submitted to the “special investigative units”, or SIUs, for further investigation. These units generally comprise experienced claims adjusters with special training in investigating fraudulent claims. These investigators are experts in cracking patterns of fraudulent claims, and look for evidence of falsification of any kind.

RAC reviews the last three years of provider claims with the help of proprietary software to identify potential payment errors in duplicate payments, mistakes of fiscal intermediaries’, medical necessity, and coding.

Unintentional errors in billing and coding should not make you liable to these audits and hamper the credibility of your practice. Experts at Medicalbillersandcoders.com have been investigating these audits closely in Florida and have found that the main reason for Insurance Fraud allegations on a clinic is when the administration is handled by novices or non-certified billers. The negligence and lack of a forum to discuss issues such as unbundling, using more expensive codes, uncertainty in the use of modifiers, and adding referrals appropriately can easily be sorted out with a network of knowledgeable billers.

PR Newswire

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Written by lordsinsurancelog

June 6, 2011 at 7:31 pm

Posted in Insurance News