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Insurance Fraud
As a Legal Nurse Consultant, I am a medical insider who knows the inner workings of our
complex health care system first hand. My professional expertise as a Registered Nurse,
Certified Registered Nurse Coder and Certified Legal Nurse Consultant, qualifies me
to perform the following services to identify Medicare and Insurance fraud .
The Federal False claims Act of 1986 was passed with the intent to help catch Medicare and Medicaid cheaters.
The Office of Inspector General (OIG) works closely with Medicare insurance companies, Federal Bureau of Investigation (FBI) Postal Inspection Services, and auditors for compliance, medical coding and billing. The OIG is the agency which investigates and prosecutes people who steal from Medicare.
Some issues include:
- Intentional deception could result in unauthorized benefits.
- A health care provider bills for services not received.
- A supplier bills Medicare for equipment different than what they provided for patient.
- Someone bills Medicare for home medical equipment after it has been returned.
- Payment of services where there is no legal entitlement.
- Physician uses excessive referrals to other providers for unnecessary services.
- Unnecessary services performed e.g MRI ( to help pay for hospital equipment).
- Coding and billing mistakes are no longer considered as negligence but as "abuse".
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Identify "unbundled" nursing services, lab, and other ancillaries that may or may not be separately billed.
See medical coding page for more particulars.
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