Fraud Health Care Fraud

With growing concerns over the rising cost of health care in the United States, health care fraud is a popular discussion point among policy makers. Health care fraud occurs when a medical provider or a consumer intentionally submits or causes someone else to submit false or misleading information to be used in determining the amount of medical insurance benefits an individual may receive. As a federal crime, this type of fraud is aggressively prosecuted, and penalties could be severe. That’s why you should always consult with an experienced Naples or Fort Lauderdale health care fraud attorney as soon as you believe you might be under investigation in or around Broward County, Florida.

Dishonest health care providers and consumers may make false representations to private insurance companies or to government programs that provide health care coverage like Medicaid. The following are a few examples of ways in which providers commit health care fraud:

  • billing insurance for services they did not perform;
  • falsifying patient diagnosis to justify unnecessary tests or procedures that are not medically necessary;
  • providers misrepresenting procedures performed to receive payment when the procedure should not be covered by insurance;
  • providers upcoding or billing for a more costly service than the one actually performed;
  • providers unbundling or billing each stage of a procedure as if each stage is its own independent proceedure;
  • providers accepting kickbacks for referrals;
  • providers waiving patient co-pays or deductibles then over-billing the insurance company;
  • providers billing patients for more than their copay amount for services that have been prepaid or paid in full under a managed care plan.

When consumers commit health care fraud, the offense often takes place in the following ways:

  • patients filing claims for medication or procedures they did not receive
  • patients forging or altering medical bills or receipts
  • patients using someone else’s coverage or insurance card
  • patients engaging in doctor shopping to obtain prescriptions for heavily regulated drugs
Just Arrested?
Do not say anything that might incriminate you. Speak with an attorney first.

Billing for services not provided

Sometimes a health care provider may defraud a private or government health care benefits provider by submitting a bill for a product or service the patient never received. For example, a doctor may bill an insurance company for treating or diagnosing a patient at an appointment that never took place. In other cases, a health care provider may examine or meet with a patient and subsequently bill the patent’s insurance company for a medical device, procedure, or diagnostic test the patient never received.

Upcoding

Health care providers may see a patient and provide a service or procedure, but some commit fraud in the manner in which they bill for the procedure. If the health care provider bills insurance for a service that is more complex than the one the patient actually received, the provider is guilty of upcoding. Surgeries provides many examples of situations that lend themselves to upcoding. Patient A may be diagnosed with a condition can be treated by performing a simple outpatient surgery. Patient B may present with the same condition, but require a more traditional, comprehensive surgery to remedy the same condition because he or she may have certain risk factors that are not a concern for Patient A. If the surgeon performs the outpatient procedure on Patient A and major surgery on Patient B, but deliberately charges both patients’ insurance policies for a major inpatient procedure, the doctor has committed an illegal act. While upcoding may happen as the result of an honest medical office error, deliberately providing a simple procedure and charging for one that is more complex constitutes fraud.

Doctor shopping

Prescription opioid addiction has reached alarming rates in communities across the United States. Florida ranks among the top states for doctor shopping; therefore, state and federal law enforcement agencies pursue doctor shopping case very aggressively in Fort Lauderdale. Patients who require opioid drugs for pain need close monitoring to minimize the likelihood of addiction. Those who become addicted often find they are unable to continue to refill their original prescription. These patients sometimes resort to visiting new doctors and misrepresenting the length of time they have been using opioids in an effort to obtain a new prescription for the highly addictive drug. In other cases, people who wish to sell or distribute opioid drugs illegally engage in doctor shopping and go to multiple facilities posing as patients who require a prescription.

Patient identity fraud

The move to digitize patient health information has made the health care system faster and more efficient. As a direct downside, medical identity theft has been on the rise. A survey conducted by the Medical Identity Fraud Alliance indicated that 60 percent of medical theft victims’ information was fraudulently used by someone closely related. The victims had either voluntarily shared their insurance information with a friend or family member or had their information stolen by someone close to them prior to the fraudulent act. In other cases, insurance and medical files may be accessed and stolen by hackers.

Legal counsel for health care fraud charges

In some cases, a person may be unexpectedly charged with health care fraud without intending to commit a crime. For example, a person may use his or her family member’s insurance card to obtain medical treatment under the consent and advice of the family member and without knowing that doing so constitutes a federal crime. In other cases, a medical office employee may incorrectly bill insurance companies at the request of his or her employer without knowing he or she is misrepresenting the service the patient received. In any case, a Fort Lauderdale health care fraud defense lawyer may be able to help people who are accused of health care fraud minimize the potentially devastating impact of a charge that may carry very severe consequences if convicted in federal court.