Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Serviceability and Service Integrity

A benefit plan, such as Medicare, and/or a private payer may provide a set of services to a defined beneficiary member. Medicaid is a recipient program, which also provides a defined set of services to a recipient. The damages with Dr. Traveler may extend further than the direct claim loss. Keep in mind, in order to get paid, a provider submits a diagnosis (the why a service was performed) and a procedure code (what was done) to the patient. Many programs provide limitations on the number and volume of services. If Dr. Traveler utilizes the allotment of a particular program or procedure, when the real patient seeks real services, such services may be denied. This can leave the patient open to an interruption of a service or compromise their health because the need for such a service has been, on paper, already fulfilled. Further, if Dr. Traveler fabricates medical records to substantiate his phantom visits, those fabricated records may be convoluted with the patients’ real records. A future legitimate doctor, dependent on the patient’s history, may make a decision resulting in a medical error due to false information.

The nursing facility that allowed Dr. Traveler to enter its premises may have damage from risk exposure. First, did the nursing facilitate violate the privacy components under Health Insurance Portability and Accountability Act of 1996 (HIPAA)? Did they facilitate the release of protected health information by allowing Dr. Traveler ...