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Physician Reimbursement Fraud: Are You A Victim?

Have you ever been sedated by general anesthesia and wonder what really occurs? A patient came into the office to receive a routine tooth extraction and to have a tooth capped. After the patient was sedated, the surgery began. The extraction went as planned and we began to proceed to cap the damaged tooth. As the surgeon examined the broken tooth, he discovered capping would not be beneficial; but to file it down. I felt as this was an act of generosity; he saved the tooth and the patient did not have to file such a large claim to the insurance company. When the case was completed the surgeon filled out the proper paper work, filed it with administration and informed the patient that the extraction and capping of the tooth went exceptionally well. While leading the patient out of the office I glanced at the super bill and under the column of procedures, the CPT code for capping a tooth was marked as if that procedure took place. As I approached the surgeon about this, I suspected it to be a mistake. How would you feel if a surgeon replied with,” they (the patient) will never know, it comes out of the insurance companies’ pocket.”

The previous account is an example of reimbursement fraud. There are accounts of physicians committing fraud, and yet, the small number of dishonest surgeons is rarely detected. Reimbursement fraud is a scheme used by employees/employers to claim a higher payout when an action or motive did not take place (Wynia, Cummins, VanGeest, & Wilson 2000). This action is against the law, and physician penalties entail: paying high fines, subject to imprisonment, and possibly termination of the practice. Misleading CPT codes are the most efficient way of reimbursement fraud in the medical field. CPT codes are a five digit number that describes medical treatment procedures and aid in billing. Physicians can easily alter cost amounts by changing one number in the CPT code. By acting on this, the physician has not only betrayed the patient, but has committed a crime, and costs insurances companies thousands of dollars.

Reimbursement fraud can be stopped in numerous ways. As a patient, after a procedure demand detailed receipts of what charges have been applied. This receipt will include all procedures that took place, co-payments collected if needed and CPT codes. The CPT codes will not make sense, but as a patient you do have the right to research what the code may interpret. Another way to protect yourself is to inquire about scheduling a conference with the staff that was present during the procedure. In doing so, you as the patient, are reinforcing your questions or concerns with an eyewitness. If you or someone you know may suspect reimbursement fraud please call 1-800-318-2596 (Palmer, 2013).


Palmer, P. (2013). How to Report Medical Billing Fraud. Retrieved from http://billadvocates.com/resources/report-medical-billing-fraud/

Wynia, M. K., Cummins, D. S., VanGeest, J. B., & Wilson, I. B. (2000). Physician manipulation of reimbursement rules for patients: between a rock and a hard place. Jama, 283(14), 1858-1865.