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3 common forms of provider health care fraud

On Behalf of | Dec 13, 2022 | Criminal Defense

Allegations of healthcare fraud can prove devastating for licensed health care providers and their support staff. For those with state licensing, criminal allegations related to one’s profession might cost them their professional licensing immediately because of disciplinary hearings. Even those who avoid immediate license penalties could still lose their license later when their criminal record shows up in the background check performed when they renew their license.

Even if you don’t need a state-issued license to do your job, you could end up not just forced out of your current position by health care fraud allegations but also facing federal prosecution. You need to recognize when company practices might put you at risk of prosecution.

What are some of the most common forms of provider-based health care fraud?

  1. Billing for treatments not provided

Perhaps the most obvious form of healthcare fraud that involves the providers themselves relates to billing for medical services they never actually provided to a patient. From fabricating appointments to adding treatments that someone never received to an appointment that did occur, there are many ways for healthcare providers to bill insurance companies or the government for treatment they never provided.

  1. Providing unnecessary treatment to bill for it

The inverse of billing for treatment not provided is providing unnecessary treatments to a patient. Basic examples would include unnecessary follow-up appointments and treatments recommended even when a patient has minimal symptoms. More serious versions might involve patients taking medications or undergoing surgical procedures that aren’t necessary at all given their current condition.

  1. Unbundling or altering billing codes

Both private insurance companies and government insurance programs like Medicaid negotiate specific reimbursement rates with healthcare providers. Often, part of that billing negotiation process involves combining certain procedures for discounted, bundled billing rates.

Intentionally unbundling combined services billed at a discounted rate is a form of fraud. It is also fraudulent to alter the billing code to charge for a slightly more expensive procedure than the one performed.

Both healthcare providers who make questionable notes in their records to optimize their billing proceeds and the support staff that submit billing claims could potentially face criminal prosecution for acts of health care fraud. Learning more about provider-based health care fraud can help those working in modern medicine avoid criminal charges.