Health care is one of the largest sectors of the modern economy. Americans spend trillions of dollars on medical care each year, making medicine one of the most stable and in-demand professions. Unfortunately, the amount of medical care required in the United States also opens the door to massive amounts of health care fraud.
Some medical practices knowingly engage in fraudulent billing. Other practices may do something considered fraud without realizing the practice violates the law. Familiarizing yourself with what constitutes fraud can help you make better decisions when it comes to handling billing claims and other issues in a medical facility.
You should never bill for anything a doctor doesn’t do
One of the more common forms of medical fraud involves billing an insurance provider, whether it’s a private company or a government insurance program like Medicare, for services that the patient did not receive.
Some practices bill existing patients for services. They might even create appointments that the patient never attends. Other companies will take it even farther by engaging in identity theft and billing patients their clinic has never seen.
Sometimes, fraud is a little more subtle. A doctor may have performed a basic procedure, but then submits a billing code for a slightly more complicated and expensive one. They could also unbundle procedures to bill for more money. That may seem like less of an issue, but it is still fraud. If government regulators or the patient realize the discrepancy, both the medical professional and the billing specialist involved in the situation could face fraud charges.
Helping patients get medical coverage for uncovered treatments
Your medical practice may want to help patients connect with the services they need. Sometimes, that could include procedures that their insurance policy specifically does not cover. It may be possible to obtain coverage if your practice submits documentation that the procedure is medically necessary.
If submitting that paperwork requires any amount of exaggerating or stretching the truth, your practice could face serious consequences. Although the patient, no doubt, appreciates your efforts, the insurance company is likely to hold you legally accountable if they figure out what happened.
Any kind of referral or kick back program could constitute fraud
Because there is so much money in medicine, there is a lot of competition for patients. Medical specialists and even drug companies can offer bonuses or other kickbacks for doctors who refer them new patients or clients.
Practices caught up in this kind of scheme could face allegations of fraud. They can also lose the trust of their patients, who will likely consider them dangerous because they put profit before people.
Whether you are a medical professional or someone who works in billing and insurance services, identifying warning signs of medical fraud is important to your professional safety. If you suspect fraud at your workplace, there are whistleblower protections in place to help you resolve the issue. If you are facing allegations of fraud, you will need to take aggressive steps to defend yourself and protect your professional future.