Some health care insurance fraud comes from consumers. They misrepresent their circumstances to secure benefits for which they may not technically be eligible. Their actions can lead to losses for the insurance company or possibly the general public if they use government insurance programs.
However, the most costly form of health insurance fraud involves providers engaging in billing fraud. Medical doctors and other professionals working in the medical field could be at risk of prosecution due to fraudulent billing activity. So could support staff members, including officer managers, coding professionals and billing specialists.
People do not necessarily need to receive direct financial benefit from fraudulent health care insurance practices to be at risk of criminal prosecution. A variety of seemingly minor billing practices can open professionals up to serious criminal charges that can result in penalties and career consequences.
Small habits can lead to serious charges
There are many types of medical billing fraud, some of which are more overt than others. People who may not even realize that their actions violate the law could be at risk of prosecution for conforming to their employer’s practices.
Obviously, billing for appointments that patients did not attend, treatments that never transpired and prescriptions that were never picked up can constitute fraud. Some medical practices try to justify billing for no-show appointments because the practice charges a cancellation fee. It may not seem unreasonable to bill insurance to those who are unfamiliar with the law.
Other forms of health care fraud may not be as instantaneously evident. For example, the manager of a medical practice might tell a new employee handling billing or coding to separate bundled charges and bill for each aspect of the procedure separately. Doing so can constitute fraud in a violation of the contract with the insurance provider.
So can upcoding, which involves billing for a more expensive procedure than the one actually performed. These small tweaks intended to make more money for a business can put the workers who use these billing hacks at risk of prosecution.
Those implicated in a fraud investigation or facing insurance fraud charges may need help responding to avoid a conviction or minimize the penalties they face. Reviewing what led to charges with a skilled legal team can help people secure the best possible outcome.