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Phantom Billing, Fake Prescriptions, and the High Cost of MedicineHealth Care Fraud and What to Do about It$
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Terry L. Leap

Print publication date: 2011

Print ISBN-13: 9780801449796

Published to Cornell Scholarship Online: August 2016

DOI: 10.7591/cornell/9780801449796.001.0001

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Fraud in Fee-for-Service and Managed Care

Fraud in Fee-for-Service and Managed Care

Different Sides of the Same Coin

(p.60) 3 Fraud in Fee-for-Service and Managed Care
Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

Terry L. Leap

Cornell University Press

This chapter examines fraud in fee-for-service systems and managed care plans. A common health care fraud that is linked directly to fee-for-service is the submission of fraudulent claims to the Medicare program. Replacement of fee-for-service health care with managed care did not end health care fraud and abuse. This chapter explains how fraud is committed in major public insurance programs, focusing on cases of false diagnoses and unnecessary treatments, medical identity theft, and overcharging for services and equipment. It also considers upcoding, unbundling, and billing for uninsured and bogus services, along with fraud and abuse in nursing homes and home health care, rent-a-patient schemes, and pill-mill schemes. Finally, it discusses the emerging drug frauds in Medicare Part D, durable medical equipment frauds, and health care frauds that save money.

Keywords:   fee-for-service systems, managed care, Medicare, health care fraud, medical identity theft, overcharging, upcoding, rent-a-patient schemes, pill-mill schemes, durable medical equipment fraud

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