The Goldberg Law Firm

Need an experienced lawyer, with a successful record at trial? Call us. 216-592-8719

We Get Results Because We Prepare for Trial
rated by super lawyers michael j. goldberg
av preemeinent rating by martindale-hubbel client champion silver 2024
“Super Lawyers is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high-degree of peer recognition and professional achievement. The patented selection process includes independent research, peer nominations and peer evaluations.”

3 acts that could constitute Medicaid or Medicare fraud

On Behalf of | Jun 18, 2024 | Financial Crimes

Professionals in the medical sector have excellent job security in general. Regardless of what happens with the economy, people always need medical intervention for illnesses and injuries. Of course, the costs that go into operating a medical business are quite high, especially when considering the wages that professionals command and the cost of malpractice insurance.

Those in the medical sector are often eager to maximize the money generated by a medical practice. Unfortunately, some attempts to increase how much money a medical practice or hospital generates could lead to accusations of Medicare or Medicaid fraud. Such allegations could potentially lead to federal prosecution. The following are some of the most common forms of Medicare and Medicaid fraud.

Billing for missed or nonexistent appointments

Many older adults need to see physicians regularly and might even have a hard time keeping track of their appointments. Some medical professionals might take advantage of that struggle by billing for appointments that don’t occur. Other times, if an older adult makes a mistake and fails to arrive for their appointment, a practice might bill for the appointment anyway in violation of insurance regulations.

Upcoding services provided

There are different billing codes used for different medical procedures. Every billing code results in a different amount of compensation based on the time and materials required to provide the service a patient requires. Sometimes, hospitals and medical practices try to increase revenue by misrepresenting the work that they performed and claiming they completed more expensive procedures for a patient. Even though the appointment is legitimate, the services provided do not align with the billing records.

Unbundling discounted services

Insurance providers, including Medicare and Medicaid reimbursement schedules with healthcare professionals. That process often involves securing discounts for bundled services typically provided together. Unbundling involves billing for each element of a service separately as a way to charge more than the agreed-upon reimbursement rate for those services. Even if the person engaging in billing fraud does not receive direct profit from their actions, they might still be at risk of prosecution.

Responding to white-collar criminal charges, like health insurance fraud, requires careful planning and an understanding of the law. An assertive defense can potentially protect someone from a conviction that could lead to their incarceration and the end of their medical career.


FindLaw Network