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Medical care providers, not patients, are the biggest source of fraud

On Behalf of | Sep 15, 2021 | Criminal Law

Health care fraud, including insurance fraud, costs government programs like Medicaid and Medicare millions of dollars a year. Many people think of patients who don’t actually qualify to receive benefits as the big source of fraud risk in the modern medical system.

While it is true that there are people who take advantage of government insurance programs when they don’t really qualify for benefits, the coverage that those people receive may only represent thousands of dollars.

On the other hand, the systemic fraud often practiced by medical professionals can cost millions of dollars in each case. While patient fraud is still an issue that insurance companies and government programs must address, health care providers remain the bigger risk for fraudulent insurance billing practices. That means all medical care providers are under scrutiny.

A single health care provider could defraud millions of dollars

Health care insurance fraud practiced by providers may start small. They might charge for two procedures instead of one or charge a patient for an appointment that they didn’t actually make or attend. As long as the patient doesn’t have any out-of-pocket expenses, the medical provider might think of their actions as a victimless crime. However, the taxpayers are the ones who ultimately shoulder the responsibility for their actions.

For example, a single ophthalmologist recently plead guilty to fraud charges that involved improperly billing for more than $3 million. He frequently upgraded the billing codes entered, claiming he had done more involved and time-consuming procedures than what he had actually performed. The funds he received came from publicly-funded insurance programs.

A patient or an employee could trigger an investigation

Understanding what constitutes fraudulent billing activity is important. You may not intend to break the law but may still have inappropriate billing practices. If a patient or someone you hire to work at your medical practice notices these issues, they might make a report that leads to an investigation and criminal prosecution.

Those accused of white-collar offenses involving health insurance fraud could face not only jail time and the loss of their medical licensing but also an obligation to repay the money they received or forfeit personal assets. Responding appropriately to allegations of white-collar criminal offenses can help limit the consequences you face.