“CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice”

“Health insurer Aetna ACE reported to federal regulators a health data breach affecting nearly 326,000 individuals tied to an apparent ransomware incident involving OneTouchPoint, a subcontractor that provides printing and mailing services to one of the insurer's vendors” (Aug 2, 2022).

Types of Medicare fraud and scams:  

There are many different ways in which illegitimate Medicare spending may be carried out: 

Double billing
This type of Medicare fraud involves deliberately charging twice for a service or product that was only performed or supplied once. 

 

Phantom billing
This involves billing for a test or procedure or other medical service that was never actually performed. This is one of the most common forms of Medicare fraud.

 

Upcoding
Upcoding is altering the codes assigned to specific billable services to reflect a higher-level service than what was actually performed. This type of scam is carried out to receive a fraudulently higher Medicare reimbursement than what is required.

 

Unbundling
This involves taking a comprehensive service and separating it into several specific services in order to bill for each one independently. This leads to a higher reimbursement total.

 

Kickbacks
Kickbacks occur when a provider accepts payment on behalf of a pharmaceutical company or medical device supplier in exchange for recommending or prescribing patients to use the product.

 

Unnecessary services
Performing an unnecessary medical service in order to receive Medicare compensation is a common form of Medicare fraud.

 

False price reporting
This occurs when false price information is submitted to Medicare regarding the true cost of a product or service.

 

Inadequate medical documentation
This involves a failure to maintain proper documentation for all products or services rendered.

 

Ineligible beneficiaries
Some Medicare scams involve providing care and filing a claim on behalf of a patient who is not an eligible beneficiary of Medicare.

 

Off-label promotion of pharmaceuticals
This type of fraud involves marketing or promoting a pharmaceutical drug for use in a way that is not detailed or recommended on the FDA approved packaging label for the drug.   

 

Unlicensed providers
Another form of Medicare fraud comes in the form of filing a Medicare claim on behalf of a health care provider that is not licensed by Medicare.

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