Criminal Background Check - Why Medical Fraud is Like an Invasive Cancer

In today’s world, identity theft is running rampant and people are suffering from irreparable loss of mega-proportions. When someone assumes another’s identity, it can wreak havoc on the victim’s ability to pay their bills due to overwhelming credit card charges and loans caused by the perpetrator. In the medical field, this type of fraud can take place with false charges of medical care that was never provided to someone. The government has suffered billions of dollars in losses since these schemes were first uncovered. Unfortunately, they continue today and subsequently cost the U.S. Government a sizable sum in false payouts for services never rendered.

Most of the physicians who provide Medi-Cal and Medicare services are honest and upstanding physicians. But in every good crop, a few bad weeds can erupt and grow among the rest. This is one reason why a criminal background check and a thorough employment background screening is vital. The key is for automated systems to be developed and task forces of investigators to be formed. Then, slight variations in services billed by these physicians can be detected and inconsistencies can be uncovered. There are systems in place right now that help to accomplish this, but nothing is perfect. Still, many fraudsters slip through the cracks and payouts are being made every day for false services.

So, who takes part in this type of scheme, you may wonder? According to the Department of Health Care Services (CDHS), there are several types of participants that have been identified. Here are their titles as well as what roles they play:

• A person who operates a laboratory or other diagnostic facility and who bills Medi-Cal or Medicare for tests on “ghost” patients who never came in for services. Referring physicians are named to try and cover their tracks, but when investigators interview them to check on the claims; they denied seeing those patients or ordering tests for them.
• Identity theft committed by a person pretending to be a valid Medi-Cal or Medicare provider and then opening a fake bank account and applying for a new provider number (usually multiple provider numbers and accounts are involved). The money for paid claims is then funneled into the fraudster’s bank account without the actual provider’s knowledge or approval.
• An individual who is paid to recruit patients and pay them for insurance fraud. One example on the CDHS Web site cited a person who picked up a van full of patients for Denti-Cal appointments at valid Denti-Cal clinics. Although the services were billed to the California-run Denti-Cal program, unlicensed individuals actually performed the services on these patients, but the fraudsters got paid by Denti-Cal as if they were actual providers.

In response to the overwhelming problem of fraud in the medical billing process, task forces, software, and investigative teams have been pulled together to help stop these false medical claims. When a provider has been convicted of crimes such as this, on a state level, many times they can escape future ramifications in other states by simply moving elsewhere. This is why a criminal background check and employment background screening are two of the best tools that hospitals and medical facilities can use to dig out the weeds before they are hired and can ruin their crops of good staff members and their facility’s excellent reputation!