Health care fraud is when an individual or entity knowingly attempts to deceive a health care benefit program using false pretenses or misrepresentations for personal interests. Physicians may commit fraud for financial gain. However, they may also do it to help their patients, particularly when a patient cannot afford out-of-pocket medical expenses.
The physician instead overbills the insurance company to cover their patient’s costs. Although the physician’s intentions are good, it is still a crime. A physician may also be guilty of fraud when they refer their patients to other health care providers.
How can a referral become a crime?
A physician usually has a specialization in a specific area. When their patient needs a service they cannot provide, they might refer that patient to someone with expertise in the required field. The physician believes they are doing what is best for their patient. For example, the physician is an orthopedic surgeon who just operated on their patient because of a torn anterior cruciate ligament (ACL). The patient may require physical therapy after the surgery, so the surgeon refers the patient to a physical therapist.
The referral becomes illegal when the physician earns from the referred services and the services are payable by Medicare or Medicaid. The health care provider may be an immediate family member or any individual or entity with whom the physician has a financial relationship. It is a violation of the Physician Self-Referral Law. While it is not necessarily fraud, the federal government may misconstrue it as health care fraud and abuse if ever an investigation occurs.
Good doctors deserve a good defense
Health care fraud is a profoundly serious crime, and the penalties are severe. The Physician Self-Referral Law does have exceptions. If the physician’s intentions were not to defraud but only to give their patient the best health care available, they do not deserve such unfair charges.