5 Reasons You Could Be Accused of Healthcare Fraud

As a healthcare service provider, you likely closely follow the philosophy behind the Hippocratic Oath. Concepts like avoiding causing harm or representing your vocation with utmost professionalism, can be followed by pretty much anyone, but those in healthcare are still held to the highest standards. What often goes unappreciated is that healthcare providers are often running a business and providing jobs. When accusations of healthcare fraud are brought up, the consequences can be dire. These accusations don’t always come out of thin air, so maintaining practical procedures to avoid these misunderstandings is a priority. 

What Exactly Is Healthcare Fraud?

Healthcare fraud refers to the intentional deception or misrepresentation of information within the healthcare system to gain unauthorized financial benefits. Accusations can arise in many ways to target medical professionals or healthcare organizations. Regulatory bodies, insurance companies, and government agencies often investigate claims of fraudulent activities based on patterns, inconsistencies, and discrepancies found in medical billing records, financial transactions, and prescription histories. Sometimes accusations come from disgruntled patients who were unsatisfied with their healthcare services, other times, a complaint could be made internally regarding consistent mistakes that appear fraudulent in nature. However the investigation is brought about, it’s important to understand which areas require the most attention.

Most Common Types of Healthcare Fraud

  1. Fraudulent Billing and Services Never Rendered: Charging for services that were never provided or billing for incorrect services can easily lead to charges of healthcare fraud. Although this sometimes happens intentionally, it can also happen when staff are not properly trained. For example, if a patient misses their appointment for a physical and the insurance company is still billed for the visit, that is considered fraudulent. 
  2. Misrepresentation of Covered Services & Upcoding: Transforming non-covered services into covered ones, with the intent to deceive insurers or government programs. This can include activities such as coding cosmetic treatment as a healthcare necessity, or performing a simple procedure and coding it as a more expensive one
  3. Failure to Collect Copayments or Deductibles: Neglecting to collect copayments or deductibles as required can lead to suspicions of fraudulent activities. Insurers usually establish co-pay waiver policies through their provider contracting procedures. It’s also crucial to note that under Medicare regulations, regularly waiving co-pays is not permitted unless it’s due to documented “financial hardship.”
  4. Excessive Treatment or Over Treating: Administering excessive treatments, medications, or services beyond what is medically necessary raises suspicions of financial motivations. It’s a fine line between ethical care and potential fraud. An example would include performing a root canal when the patient only needs a small filling.
  5. Falsified Diagnoses: Manipulating patients’ diagnoses and medical records to justify unnecessary tests, surgeries, or procedures. This may look like a physician claiming a patient has a non-existent ailment that needs further treatment, thus increasing the potential insurance payout.

Proactively Protecting Your Interests

It’s not always possible to avoid healthcare fraud allegations, but there are ways to improve your position. All healthcare providers should have documentation procedures and internal audit policies. Thorough documentation of all services, testing, and billing can negate false accusations. However, not all healthcare providers have the authority to ensure the enforcement of these practices. In these situations, meticulously documenting activity can provide a trail of breadcrumbs that leads to evidence of good faith treatment plans or billing procedures. 

If you find yourself accused of healthcare fraud, your next steps must be immediate and strategic in order to protect your rights. The first and most crucial step is to consult with experienced healthcare fraud defense attorneys, like the law firm of Weisberg Kainen Mark. We can help you navigate your options and provide insight on the challenges to come. To start working toward a favorable resolution, call our office at (305) 374-5544.

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