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In this case a provider does not submit exactly the same bill, but changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice. [5]
The third and final party is the payor, typically an insurance company, which facilitates reimbursement for the services rendered. Medical billing involves creating invoices for services rendered to patients, a process known as the billing cycle or Revenue Cycle Management (RCM). [12]
Provider fraud consists of claims submitted by medical care providers, and may include billing for services not rendered, billing for higher level of services than those provided, making false statements on claims submissions, double-billing by doctors who charge more than once for the same service, performance of unnecessary medical treatments ...
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Crimes of this sort are typically prosecuted as larceny, and may be either a misdemeanor or a felony, based upon the value of the services illegally obtained.This category encompasses a wide variety of criminal activity including tampering with (or bypassing) a utility meter so that the true level of consumption is understated, leaving a hotel or restaurant or similar establishment without ...
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The most common form of kickback involves a vendor submitting a fraudulent or inflated invoice (often for goods or services which were not needed, of inferior quality, or both), with an employee of the victim company assisting in securing payment. For their assistance in securing payment, the individual receives some sort of payment (cash ...
Providers may seek to maximize profit by avoiding patients for whom reimbursement may be inadequate (e.g., patients who do not take their drugs as prescribed), by overstating the severity of an illness, by giving the lowest level of service possible, by not diagnosing complications of a treatment before the end date of the bundled payment, or ...