09:07 AM

Four Ways to Fraud-Proof Your Practice


"If it sounds too good to be true, it probably is."

That adage rings true whether you’re buying a car or entering into a new business relationship. With health spending in America now accounting for close to 20% of the GDP, the temptation to cut corners, bend the rules, or cheat the health care system to tap into the $3.5 trillion revenue stream has never been greater.

Timothy DineenBy Timothy Dineen, CFE, HCISPP, Director, Special Investigations

Unscrupulous actors looking to cash in are constantly developing new scams and too often they ensnare an unsuspecting physician.

Thousands of indictments and convictions are filed against doctors and other health care providers each year by federal and state authorities. Health insurers are employing sophisticated tools able to detect even the most subtle changes in billing or utilization patterns in order to protect their policyholders from fraud.

Illicit activity by bad actors can be subtle in terms of how you may be approached as a health care provider. When you reflect on these “opportunities” you may find that what they are offering you is in fact too good to be true. Below are some examples:


Too good to be true?

Offers to rent office space for lab testing or other services

The rent they are offering is far beyond market rates

Reviewing patient medical records online to evaluate for medical necessity and write a script/order for medication or DME

The “medical records” are not medical records at all nor supportive of a script/order

Procedure code guidance from a medical device sales representative

The procedure code suggested does not reflect the service that is being rendered

These bad actors understand that providers are the gateway to the insurance system. Providers are the first stop for patients seeking help and everything that follows – including payments - flows from that interaction. It’s possible to get duped or swayed by bad actors regardless of your good intentions. The result can sometimes be health care fraud costing Americans tens of billions of dollars annually, according to the National Heath Care Anti-Fraud Association.

Horizon’s Special Investigations works with providers, consumers, law enforcement agencies and other stakeholders to detect and prevent fraudulent activity. The following are some tips for providers to help avoid situations that may lead to fraudulent activity:

Just say no … to kickbacks. Any third-party organization, such as a laboratory, that offers you money or goods in return for using its services is most likely breaking the law.

Know the rules. Many fraudulent schemes in recent years are tied to emerging practices, like telemedicine, which have specific rules and regulations. Don’t engage in an unfamiliar practice without understanding the laws that guide it.

Beware of unsolicited advice. Phrases like “no cost to your patients” or “I can double your revenue” are red flags. You should always evaluate an arrangement that seems too easy and too lucrative.

Trust your instincts. As a highly-trained physician, you understand the practice of medicine better than any outside advisor or promoter. Trust your instincts and do your research, including counsel from a trusted advisor, before engaging in any new arrangement.

If you suspect insurance fraud, please call any of the Horizon Fraud Hotlines listed below. The Hotlines are confidential and you can remain anonymous.

1-800-624-2048 – Horizon BCBSNJ Fraud Hotline

1-855-FRAUD20 (1-855-372-8320) - Horizon NJHealth (Medicaid) Fraud Hotline

1-888-889-2231 – Horizon BCBSNJ Medicare Fraud Waste and Abuse Fraud Hotline