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Seemingly smart medical billing practices could send you to jail

| Jan 19, 2021 | Federal Crimes |

People think of medicine as a lucrative career, but many physicians with small practices operate on a shoestring budget. If you have your own private practice or manage a small practice with a few other professionals, every patient visit and procedure matters.

Timely billing and quick payments are probably crucial to your ability to keep paying your own bills and maintaining the best facilities possible. Increasing revenue would be ideal, but it is hard to do. Finding new patients can be difficult and you might try to increase profits by employing creative billing strategies.

Unfortunately, the very same practices that might seem like a way to increase company profits without pushing any more expenses on the patient might leave you at risk of insurance fraud charges.

You can only bill for medically necessary procedures you perform

If you perform a procedure for a patient and there is a similar procedure that requires the same amount of time and the same equipment but offers a higher reimbursement rate, you might feel tempted to bill for the higher-paying procedure.

After all, that doesn’t necessarily mean your patient has any more costs. In fact, you might even consider adding a few extra procedures or expenses to the bills that you submit to the insurance company because it means more revenue without more patient costs. If you get caught inflating your charges by a private insurance company or federal insurance program, criminal charges could easily result.

You can’t charge individually for services discounted in a group

If you are an in-network provider for an insurance plan, you generally sign a contract agreeing to specific compensation rates for different procedures. Bundling services together is a common insurance negotiation tactic. Given that pain relief and anesthesia always occur with a minor surgery, they may negotiate a slightly cheaper price for those services provided together.

You have to bill at the rate you agreed to in the contract with the insurance company. If you try to break apart the procedures and charge for each service separately, that is unbundling. Unbundling is a common source of insurance billing fraud.

Although slightly inflating what you charge patients for their care may seem like a negligible issue, it is a criminal act. If the insurance program is government-based, you could potentially face federal charges. Any medical professional accused of insurance fraud or similar offenses risks not only their freedom but also potentially their license to practice medicine. A strong defense is crucial for professionals hoping to move past a pending charge.

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