People involved in white-collar crime may not realize that their actions violate federal law and put them at risk of fraud charges. Some people accused of fraud might not even personally benefit from their actions.
Physicians, practice managers and billing specialists in the medical field could all wind up implicated in insurance or medical billing fraud allegations through what they may see as basic business practices. Understanding certain common billing practices that constitute insurance fraud can help you identify if your employer has engaged in questionable behavior or if your own billing practices might be risky.
Medical practices can only bill for the exact services rendered
One of the most common forms of insurance fraud involves a doctor or biller charging for services that a patient didn’t receive. In some cases, a physician or someone involved in billing identifies a patient who likely won’t notice unusual charges popping up on their insurance. Older adults and people on state insurance are frequently targets of this kind of fraud. The provider will bill for services that the patient never received or appointments that never even happened.
Another form of fraud that is similar involves changing the description of the services provided in order to bill for a more expensive service than the care that a patient actually received while in an office.
Unbundling to maximize billing is also a form of fraud
Both government insurance programs and private insurance companies negotiate specific rates of compensation with in-network providers. The medical professionals or practices agree to accept a specific amount of compensation for their services in order to take that kind of insurance.
Often, services that go together, like anesthesia before a biopsy, will have a single billing code for the discounted rate negotiated as part of the contract. If the physician or their billing specialist intentionally separates out individual services that should get bundled together in order to maximize how much they charge, that could also result in fraud charges due to unbundling.
There are a host of other ways in which medical practices can charge more than they should for services they provide or otherwise take advantage of the insurance billing system for their profit and not the benefit of their patients.