Healthcare fraud is a national concern that affects millions of Americans. Because the government loses billions of dollars annually, the federal government and the Attorney General’s Office dedicate immense amounts of resources to investigate and prosecute those accused of committing health care fraud.
Therefore, as a provider, you need to understand that even some unintentional mistakes can trigger an investigation.
Common billing issues that can trigger a healthcare fraud investigation
While every situation is unique, there are some common issues that tend to raise red flags:
- Double charging: This may happen accidentally and sometimes on purpose. This often happens if a patient has Medicare and private insurance.
- Medically unnecessary treatments: Providing treatment that isn’t considered necessary for the specific condition may trigger an inquiry.
- Unbundling a claim: Providers may charge more than they should by billing items that should be bundled together separately.
- Upcoding: This may happen when a physician bills for a more expensive service than what was provided.
Can you prevent medical billing issues?
Medical billing processes require special attention, but there are some steps you can take to prevent common medical billing issues. This includes implementing a strong compliance program, understanding healthcare fraud laws and improving medical billing processes.
Can you defend yourself if accused of medical billing fraud?
Unfortunately, even honest billing mistakes may have disastrous consequences. You could face arrest and indictment if you’re accused of medical billing fraud. However, there are legal defenses that you can use to challenge the accusations aggressively, such as:
- Lack of intent: To be convicted, it has to be proven that you intentionally tried to defraud the insurer or the government.
- Lack of knowledge of fraud: If during investigation it’s found that most of the bills were higher, you can defend yourself by proving you were unaware of the improprieties. If the element of knowledge isn’t proven, the case may be dismissed. This means you can only use this defense if your nurse or medical billing specialist has made claims incorrectly and without your knowledge.
Healthcare billing rules and regulations are complex; unfortunately, even honest billing mistakes can have far-reaching consequences. Therefore, if you’ve been accused of medical billing fraud, you should consider seeking legal assistance to protect yourself and the reputation of your business.