Our Mailing List

Legal training that you would not find anywhere else!


The Fine Line of Legit Claims Vs Abusive

Abuse and fraud are costly and quite widespread tody. Be it in the corporate world as seen by the UUtech Vs Getty Images case or in the health sector. Fraud is intentional misinterpretation and deception meant for illegal benefit, such as billing for non-rendered services. 

Abuse in the health sector is unfair charging, charging for medically unnecessary service or for those that are unprofessional, such as testing more patients than the ones who require to be tested. Abuse and fraud are similar, but it is impossible to prove that an abusive act was done with fraudulent intentions.

Insurance fraud has led to losses in billions per year. In 1998, it was proven that 1 seventh of the money for medical care was lost to abuse and fraud.

Type of Abuse and Fraud 

False claimants are among the most common scams in medical insurance fraud. They aim at receiving payments for certain claims like:

Billing for non-rendered procedures, supplies and services.

Misrepresentation of a provision; who provided it, when and to whom, and what the provision entailed, the diagnosis or condition or diagnosis and the costs involved.

Unnecessary service provision or test orders.

Most insurance policies cater for part the doctor’s usual fee. Some doctors charge more for insured patients and report a higher fee to their insurers. This is unlawful, just as it is to regularly exempt patients from deductibles and copayments. A deductible is paid before payment by the insurer while a copayment is a fixed amount by an insured patient for a specific service. Reduction of charges for patients that are genuinely struggling financially is legal, but it is illegal to offer discounts and free services to every uninsured patient. 

Research shows that making patients pay for services will reduce the chances of them asking for unnecessary services. Routine waivers therefore increase health expenses. They are fraudulent since averaging the physician’s full pay with them would lower the usual pay.

Other illegal activities are:

• Charging for unperformed services.

• Unbundling claims: Separate billing for collectively covered procedures, such as a podiatrist operating on two toes and claiming for two separate operations.

• Double billing: Billing for a service two or more times.

• Upcoding: Billing for a harder service than the one performed. This is billing for more complex or longer office visits, like billing for a complete visit after a brief consultation. It also involves billing for harder procedures or equipment that is more expensive than the one delivered. Documentation guidelines by Medicare state the components of different services.

• Miscoding: Using the wrong code number.

• Kickbacks: Receiving benefits or payment for referral. Indirect kickbacks involve paying more for something valuable. For instance, a vendor whose business relies on doctor referrals can pay higher rent to doctors owning the refer patients and premises, or an on-motion testing service performing diagnoses in a physician's office. Kickbacks can disrupt medical decisions, cause overusing, raise costs, and lead to unfair competition through freezing out those competitors who don’t pay kickbacks. Additionally, patient care can deteriorate since doctors would perform their services based on the profits they will gain.  The Inspector General’s Office, in 2012 presented a fraud caution against rental payments made as kickbacks.

Criminals at times get Medicare numbers due to deceptive billing through health surveys, free health screening, paying the beneficiaries for showing up, getting beneficiary names from boarding facilities or nursing homes, or providing "free" supplies, food or services to beneficiaries.

Inappropriate or Excessive Testing

Most standard tests help in some cases but not others. Chiropractors are notorious for charging for unnecessary tests. The most abused tests are:

• Computerized inclinometry: This is measurement of joint flexibility. It is necessary for disability analysis, but it should not be done repetitively.

• Nerve conduction test: They test nerve functioning for many degenerative conditions and some injuries. They should not be done for checking the patient’s progress.

• Surface electromyography: It measures the muscles’ electrical activity, and various kinds of performance at work. Some chiropractors, however, illegally use the test for  subluxations screening and checking patients’ progress.

• Thermography: It provides images showing the temperature between body sides. Chiropractors falsely use it for finding nerve irritation or impingements and for checking the impact of their subluxations’ adjustments. 

• Ultrasound screening: It has many purposes. However, it cannot be used for inflammation or muscle spasm diagnosis, or for checking patients’ progress.

• Unnecessary x-rays: They are done on conditions that need medical referral. Chiroprators, however falsely use them to check for subluxations or check the progress of spinal patients.

• Spinal videofluoroscopy: It records and produces spinal x-ray pictures showing the level of restricted joint motion. This can be done practically, like making the patient bend.

Many insurers complain about chiropractics’ maintenance care claims for symptomless patients, an uncovered service. Most insurers review the claims if they go beyond 12. Some chiropractors give new diagnoses after 12 visits to evade review.

Mills for Personal Injury

Corrupt advocates and medical-care providers combine to charge for minor injuries and non-existent ones. They pay runners or "cappers" to recruit fake or legitimate employee compensation claimants or car accident victims. Victims are told to visit many times. The providers fake reports and diagnoses and give unnecessary costly services. Advocates then negotiate fraudulent medical claim settlements. The claimants could be knowing or innocent. Milling is suspected in case of submission of different cases from few providers.

Quackery-Based Miscoding

Insurers, while processing claims, use procedural and diagnostic codes. They use computers which detect uninsured services. Most policies exclude trial or nonstandard methods. Most nonstandard experts misrepresent their services or diagnoses. There are endless resources that can tell you more on false claims.

Happy Client

Searching for a reputable legal training centre in the UK. Just complete the form below and let us help you in becoming a successful lawyer.

Finding a good legal training centre that had experienced lawyers looked impossible until I heard about Legal Trainee UK. I attended their training program and am currently doing very well in my career all thanks to the highly qualified lawyers I received my training from!
Mitchell J. Lewis

Happy Client

Searching for a reputable legal training centre in the UK. Just complete the form below and let us help you in becoming a successful lawyer.

I was feeling stressed out because I was having difficulty in locating a training centre that offered legal training for a reasonable fee. But then I found out about Legal Trainee UK and their affordable training programs which equipped me with the necessary skills that have helped me in excelling in my career!
Chris H. Dempsey