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Provider Fraud

Fraud by physicians and other providers, including ambulatory surgical centers, clinics, and physical and occupational therapists, can take many forms.

  • Billing for procedures and services not provided
  • Billing for services and procedures not medically necessary
  • Upcoding lower cost services and procedures for higher ones
  • Billing for services never rendered
  • Billing for services performed by unlicensed personnel or at an unlicensed location

In addition, physicians have relationships with payers, other providers, and vendors, making them vulnerable to fraud under the Anti-Kickback Statute and Stark Law. Physician fraud under the AKS involves physicians knowingly or willfully offering, paying, soliciting, or receiving any type of remuneration to induce or reward patient referrals. In addition, the Stark Law prohibits physicians from making referrals for certain designated health services to entities in which the doctor or the doctor’s family member has a financial interest, including an ownership, investment, or compensation interest other than one permitted under the law. When such a health service has been provided in violation of the Stark Law, it is unlawful for a claim for that service to be submitted to Medicare.

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