Pundits and commentators often discuss people seeking benefits for which they are not eligible. Particularly in scenarios involving government insurance programs, including Medicare and Medicaid, people tend to focus on individuals trying to secure coverage or benefits that they may not actually deserve. However, when looking at what actually costs government insurance programs and private insurance providers the most money, fraud related to medical billing is a much more serious issue.
What behavior could potentially constitute health care fraud in the billing and coding sectors of the medical world?
Unbundling charges
Insurance providers and government programs have specific rates of reimbursement that they provide for different services. Bundling services provided together for a discount is standard practice. If billing and coding specialists separate a bundled service and bill for each aspect separately to maximize revenue, that could lead to allegations of fraud.
Upcoding
Upcoding is another common, seemingly minor, form of healthcare fraud. Coding or billing specialists choose to alter records to bill for a more expensive procedure than the one actually performed. They may view this as fair and appropriate, especially if the original service and the one they bill for involved the same amount of time and the same equipment.
Billing for missed appointments
Insurance only pays for appointments attended by patients. Many medical practices have fees for missed appointments, as last-minute cancellations or no-shows represent an appointment that a paying patient could have taken. Charging a patient a fee for that time is legal, but billing for services not rendered is an active fraud.
There are numerous other billing decisions that could lead to fraud charges against health care professionals and the support professionals staffing medical offices. In some cases, those accused of health care fraud may have simply followed instructions from a supervisor or the training they received from their employer. There could be a reasonable explanation for behavior that initially appears fraudulent.
Discussing employment arrangements and pending charges with a skilled legal team can help medical professionals respond effectively to white-collar criminal charges related to billing practices. Otherwise, allegations of health care fraud could lead to orders of restitution, incarceration and long-term career setbacks.