Stories of healthcare fraud might focus on dramatized tales of undocumented immigrants or unscrupulous people lying to get coverage that they should not have received. However, such fraud is only a portion of the annual health care fraud that occurs in the United States.
The biggest losses reported related to Medicare and Medicaid fraud frequently stem from provider offenses rather than patients getting benefits for which they don’t actually qualify. Healthcare providers who accept Medicare or Medicaid might engage in certain billing practices that actually violate the law and become fraud.
What are some of the billing practices that could lead to healthcare fraud allegations against medical service providers or employees at medical practices?
Altering or fabricating charges
Maybe a patient underwent a low-cost procedure, but there is a more expensive but similar medical treatment that would work for the same condition. Altering the billing code to get more payment for services rendered could lead to fraud allegations.
So could making up fake appointments or entering codes for treatments that a patient didn’t receive during their appointment. Billing for services not rendered or upcoding to charge for more expensive services are both fraud. So is changing someone’s diagnosis to treat them for a more expensive condition.
Unbundling discounted services
Medicaid and Medicare require that health care providers agree to certain reimbursement rates to accept government insurance. It is common practice to combine certain charges and have them cost less as a unit than they would as individual services.
If a health care provider subject to a contract with bundled service discounts separates each task and charges for them individually to get more money for the same treatment, that could potentially lead to healthcare fraud charges as well. Although the changes may seem minor, they add up to a significant amount of money when performed over and over again.
The manager of the practice or the healthcare provider receiving reimbursement for their work won’t be the only ones at risk of criminal charges in such a scenario. Anyone aware of or involved in the fraud could also face charges. Recognizing when company practices put you at risk of white-collar criminal charges could help you protect your freedom and your profession.