Allegations of healthcare fraud may lead to federal prosecution. Healthcare providers and members of their support staff, ranging from coders and billers to office managers, could face accusations of healthcare fraud that lead to significant criminal penalties.
Billing practices are often a key element of a healthcare fraud charge. Certain behaviors that may seem reasonable or profitable could actually constitute violations of the law and trigger investigations that could lead to federal charges.
What common billing practices actually violate federal regulations and leave people at risk of prosecution?
1. Phantom billing
Patients are not always reliable. They may fail to show up for an appointment or to collect their prescription from a pharmacy. Many companies now charge a canceled appointment fee for this exact scenario. That fee must come directly from the patient. Billing for a missed appointment or a prescription not picked up by a patient is a form of fraud, even if the intent was to protect a patient from direct financial responsibility for the fee imposed by the business.
2. Unbundling
Insurance providers and government insurance programs negotiate discounted rates for combined services. This bundling process helps limit overall medical expenses, but it also puts pressure on the profit margins of medical businesses. Unbundling involves separating discounted services to bill for each on its own. Unbundling may seem reasonable, but it is a contract violation and a form of insurance fraud.
3. Upcoding
The amount of payment provided depends on the services rendered. The payment schedule looks at the time involved, the materials used and the skills of the professional providing care. In some cases, there may be multiple different charges or billing codes that involve the same materials and professionals. Upcoding involves changing the billing code entered to a more expensive procedure or treatment than the one actually provided to the patient.
Individual medical professionals who input inaccurate information into records, insurance coders and billing specialists are all theoretically vulnerable to criminal prosecution due to questionable insurance practices. Reviewing alleged financial misconduct with a white-collar criminal defense attorney can help those accused of healthcare fraud determine the strength of the case against them and evaluate options for defending against those charges.
