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A form of health care fraud that may not seem like a crime

On Behalf of | Dec 9, 2022 | Criminal Defense

Certain forms of health care fraud are unquestionably illegal and unethical. For example, telling a patient they have a medical condition that they do not and then performing treatments on them or sedating them so that they think they will undergo treatment is an incredibly cruel act. There have been cases of people who have undergone unnecessary surgery because of what is effectively insurance fraud.

Both the medical professionals providing care and their office support staff will typically shy away from or speak up about misconduct that would harm a patient’s health. However, there are other, seemingly victimless forms of healthcare fraud that people don’t always realize are illegal. One, in particular, is both common and seemingly innocent.

Unbundling procedures could lead to criminal charges

Insurance companies negotiate reimbursement rates for services with individual healthcare providers and specific facilities. They set certain reduced rates for common procedures, which helps them save money.

One of the ways that they can limit how much they pay is by bundling services together. If there are three separate components to a treatment for a condition, the insurance company may negotiate a discounted payment schedule for when patients undergo those treatments at the same time.

Those trying to maximize how much money a medical practice brings in might look at the discounted billing in amounts and decide it is a better idea to resume charging for each of the services individually. Although this seems like a simple and easy way to secure more money without harming patients, it is a known form of fraud and a violation of the contract with insurance providers.

Both those accused of improperly billing private insurance companies and those who employ unbundling and other questionable practices while accepting government insurance benefits like Medicare could potentially face criminal charges.

Personal profit isn’t necessary for a crime to occur

Since you aren’t the one who owns the practice, you might think that your actions in the billing department would not lead to criminal consequences for you as an individual. However, anyone aware of and involved in healthcare fraud could end up implicated as an individual or as part of a broader conspiracy. The charges that they face could result in jail time or leave them on able to continue working in the medical profession.

Learning more about what may constitute health care fraud could help you avoid unintentionally committing this common white-collar crime.