If you run your own small medical practice as a physical therapist, physician or other medical specialist, it can be very hard to compete with bigger, corporate practices while still commanding a living wage. After all, you probably need at least one support staff member and have years of student loans to pay.
You may want to be able to offer patients competitive prices but need to be able to cover all of your facility costs and staff expenses. One way that some people might try to turn a profit as a small medical practice could involve finessing how they handle insurance billing.
It may seem like no big deal to charge for a slightly more expensive procedure than the one you actually performed or to bill separately for services usually billed together at a discounted rate. The goal is to keep providing good care to your patients while covering your salary and expenses. Unfortunately, many ways that physicians might maximize their income could constitute medical billing fraud.
You should only bill for what you do
Creating a fake appointment for patients you see at your practice and billing their insurance for a minor procedure that you didn’t perform might seem like a victimless crime because your patient doesn’t have any financial consequences.
However, billing for services you did not provide or billing for more expensive alternative services and treatments than what a patient received are forms of medical billing fraud and could result in charges, especially if the patient notices the billing discrepancy and alerts someone.
Billing practices should comply with your insurance agreements
In order to accept certain kinds of insurance as an in-network provider, you typically have to agree to specific terms and compensation rates.
When you intentionally try to work around that system and charge more than the insurance company would usually pay for something, it is a form of billing fraud. Charging individually for bundled services or attempting to charge a different price than the one agreed upon could result in fraud allegations.
Insurance billing fraud can be a mistake that ends your medical career and could even result in federal criminal charges if the insurance involved is a government benefit. Anyone facing charges related to medical billing will likely need help strategizing for their criminal defense needs.