If a resident, their family member, or responsible party/bill payer sees discrepancies in statements from insurance companies, they should check with the doctor’s office. If they are not satisfied with the response they receive,they should notify the carrier, as well as any appropriate regulatory agencies.
Risk Management Perspective
Policy/Procedure: A goal is to establish transparency in whatever the process is so the healthcare provider and their trusted compliance and ethics team are able to see what is going on, so even if they are a half step behind they will able to mitigate the damage and make sure it does not happen again.
Training: Compliance and ethics code of conduct must be continuously presented to employees, independent contractors, temporary staff, vendors, and all other participants in the total delivery of care.
Audit: Policies and procedures need to promote transparency so that auditing can be effective. Periodically assess the policies and procedures and their implementation to ensure they are comprehensive, complete, and current. Auditing needs to reflect multiple sources of oversight.
A Chicago psychologist has been indicted on federal fraud charges for allegedly submitting false claims to Medicare and private insurers. From 2011 to January 2018, she submitted fraudulent claims to Medicare and private insurers for mental health services that were not rendered, the indictment states. In some instances, she was out of the state on the dates she claimed to have provided the services. She also used some of her patients’ names and dates of birth without their knowledge to create fictitious claim forms for the purported services. The indictment charges her with five counts of healthcare fraud and three counts of aggravated identity theft.
