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3 billing tactics that could result in health care fraud charges

On Behalf of | Oct 31, 2022 | Criminal Law

The health care industry is one of the biggest sectors of the modern economy. Despite the scope of the healthcare industry and how lucrative it can be for certain parties, it is not necessarily as profitable as people think. Medical professionals running their own small practices and trying to compete with bigger businesses often have to get a little creative.

They may structure their practice differently than others in the same area of medicine, or they may use a truly unusual approach to advertising in the hopes of appealing to more patients for the practice. Sometimes, it will be the billing practices that are a bit different.

The medical professional or a member of their support staff might use a creative strategy to increase how much revenue they built for each month. Unfortunately, some of the clever tactics that could lead to more revenue could also potentially lead to healthcare fraud allegations. What are some of the more common sources of billing fraud committed by health care providers?

Upcoding for services rendered

A patient came in and required 20 minutes of the doctor’s attention and specific materials. The physician performed a particular treatment, but there is another procedure that would cost more and mean a bigger payment from Medicare, Medicaid or a health insurance company.

However, upcoding is a common form of fraud. Charging for a procedure other than the one actually performed could lead to allegations of billing fraud.

Charging for services never provided

Maybe a patient called in to cancel their appointment at the last minute, and someone in the office submitted a billing claim because it seemed unfair to lose out on the money the practice could have earned for that time. Perhaps someone at the practice came up with the idea of billing for appointments that had not occurred because they thought it would be a victimless crime as long as you did not try to collect a copay or coinsurance from the patient.

A patient who receives notice of billing for an appointment they did not attend could very well decide to report the issue to their insurance provider, which could result in an investigation and criminal charges.

Unbundling a claim

When you sign a contract to accept certain forms of insurance, you agree to certain fee schedules and compensation rates. Part of that agreement involves allowing a discounted reimbursement rate for certain services provided together, like localized pain relief when excising a mole.

If a practice intentionally separates charges and bills for them separately to maximize how much it charges, that practice of unbundling discounted services could also lead to accusations of health care fraud.

The doctor entering certain billing codes in their records, the person managing the billing department and even individual billing professionals could end up facing charges related to billing fraud in the healthcare industry. Those professionals don’t necessarily need to directly profit from the fraud to have some criminal responsibility for the scheme. Reviewing your current billing practices to ensure they align with the law can protect you and your coworkers from health care fraud charges.