Health care fraud or insurance fraud is a relatively common white-collar crime. There are countless medical appointments taking place on any given day, and each appointment results in specialized billing efforts. Most medical facilities follow strict rules when billing private insurance providers and government insurance programs, like Medicare.
A few may bend rules in a way that could lead to criminal prosecution. People simply trying to make ends meet in the cut-throat world of for-profit medicine may find that their clever tactics backfire. Independent medical practices, in particular, may struggle to establish themselves financially.
Occasionally, physicians or the professionals working for them use creative billing practices as a way of maximizing company revenue. What seems like a clever tactic initially can endanger the future of the professional practice. The people involved in modified billing schemes might end up facing federal criminal charges for what may seem like a perfectly harmless billing practice.
Insurance rules are strict
Billing insurance is a complicated process that involves inputting specific codes related to the procedure performed. Insurance companies only cover specific procedures and negotiate specific costs for those procedures with health care providers ahead of time. Deviations from billing rules can lead to allegations of health care fraud.
Some medical practices actually bill for appointments that did not occur or services not provided to patients. Those situations might very well lead to fraud charges for the physician or billing professionals involved. There are also occasionally cases in which health care providers perform unnecessary procedures just to bill for them later.
Outside of such egregious health care fraud, there are smaller, seemingly innocent acts that might lead to criminal charges. Upcoding is a term for scenarios where a professional bills for a more expensive procedure than the one they performed. It is also inappropriate to unbundle discounted medical services by billing for each element separately instead of at a pre-arranged discounted rate.
Acts that may not seem particularly malicious or even outright fraudulent can constitute actionable health care fraud and may lead to white-collar criminal charges. Those accused of health care fraud may need to respond assertively to protect their reputation, professional licensing and freedom. Health care fraud charges can lead to criminal consequences and may also result in professional penalties that can derail a career permanently if a defense strategy isn’t successful.