Home > Fraud Awareness, SID Information > Extreme [con] games: Providers billing for unnecessary or non-rendered services.

Extreme [con] games: Providers billing for unnecessary or non-rendered services.

Billing document with penMost providers, in faithfulness to their patients and profession, avoid the extremes. Indeed, they accomplish their life’s mission as described in the modern version of the traditional Hippocratic Oath, by Dr. Louis Lasagna, in the profound words:

“I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism” [non-treatment].

Admittedly, even the best providers, through simple, human frailty, will sometimes fail. Occasionally, they over treat one patient and under treat another. As unfortunate as these occurrences are, they are certainly not criminal acts.

Yet, still other providers do, in fact, commit a crime when they over treat or under treat. Here’s how. The criminal provider engages in a pattern of intentional over treatment or non-treatment of patient(s). He or she attempts to deceive BWC, and/or other insurers, by submitting fabricated medical reports to justify falsified bills demanding payment for their unnecessary or non-rendered services. In the latter instance, the criminal provider displays brazen arrogance in submitting any bill for a service that was not provided to a patient. Millions of ‘reasonable people on the street’ have no difficulty deeming such acts as criminal. Thus, jurors appropriately hand down guilty verdicts in our criminal prosecution cases.

A Case In Point

We received an allegation from a managed care organization employee that a provider was billing for durable medical equipment not provided to claimants. The SID Health Care Provider Team (HCPT) interviewed patients and analyzed medical records. The investigation found the provider submitted fraudulent patient progress reports to BWC for reimbursement of medical supplies she did not provide to her claimants.

The subject pled guilty to one fifth-degree felony count of workers’ compensation fraud. The court sentenced her to serve one year of incarceration (suspended) and one year of community control, and to perform 80 hours of community service. The court ordered the subject to pay BWC $11,154: $5,577 in restitution and $5,577 investigative costs.

Be on the Lookout

Red flags that may indicate a provider is engaging in billing for unnecessary or non-rendered services:

  • The provider ignores a patient’s or guardian’s questions about the necessity of a treatment;
  • The provider dismisses a patient’s or guardian’s necessity of a treatment questions with the excuse:  “It will cost the patient nothing; the Bureau or another insurer will cover the expense.
  • An “explanation of benefits” statement from BWC and/or another insurer lists services the patient does not recall receiving from the provider;
  • An “explanation of benefits” statement from BWC and/or another insurer lists dates of services on which the patient was not seen or treated by the provider, perhaps due to a canceled appointment; and
  • An “explanation of benefits” statement from BWC and/or another insurer lists non-feasible dates of service, dates when the provider would not have been available, perhaps on a weekend or holiday.

Look for our next fraud provider awareness article that will discuss providers who practice without a valid license. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject is committing workers’ compensation fraud, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

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  1. October 11, 2013 at 11:03 am

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