False treatment reimbursement claims

Healthcare providers issue false reimbursement claims to increase the disbursements that they receive from the payer. They can occur in several ways: healthcare providers can claim for services that were not actually provided; healthcare providers can claim for services that were not actually needed by the patient; and healthcare providers can over-invoice and state that the patient had a more severe condition than they actually had, a practice called ‘upcoding’.

This corruption type has an inherent vulnerability: patients may only know as much about the treatment received as the healthcare provider has told them, and payers such as insurance funds are limited in how much they can check about the delivery of the treatment. It is harder for payers to detect overbilling than undelivered services, as the doctor may give a seemingly good clinical reason for the treatment. Patients are less likely to be aware if something was done rather than nothing at all.

This type of corruption is common where there is a fee-for-service reimbursement. In the USA it is one of the most prevalent forms of healthcare fraud, with considerable national resources devoted to its detection and elimination.

The corruption type unnecessary referrals and procedures in the delivery of healthcare services category also covers this issue. However, in contrast to this corruption type, it focuses solely on the process of a healthcare provider making a false claim to a payer for unnecessary procedures.