Healthcare fraud remains one of the most active areas of criminal and civil investigation and enforcement/prosecution by the federal government and the states. In this article, you’ll discover the most common types of healthcare fraud medical providers commit and what you can do about it if you’re being investigated.
The government estimates that healthcare fraud amounts to billions of dollars lost annually and burdens consumers with higher health insurance premiums, out-of-pocket expenses, and taxes.
Investigations of healthcare fraud can focus on entities comprising the healthcare system—pharmacies, hospitals, doctors, pharmaceutical companies, and equipment providers. Providers found to engage in fraudulent schemes deliberately may face administrative, civil, and criminal sanctions under several federal and state laws.
Penalties may be prison sentences, fines, damages, and exclusion from healthcare programs, including Medicare and Medicaid.
No matter where you work in healthcare, arming yourself with knowledge about the common types of fraud and abuse in the medical setting is essential to avoiding involvement in such illicit conduct and meeting the challenge of an investigation or inquiry.
What Constitutes Healthcare Fraud?
Healthcare fraud happens when there is intentional deception or misrepresentation committed with the intent of gaining an unauthorized benefit for a person or entity.
Fraudulent conduct may be difficult to detect or prove because fraudulent activities by medical professionals appear to be legitimate transactions. Payments get cleared easily since large financial transactions rarely get questioned due to the expensive nature of pharmaceuticals and other services. Therefore, healthcare fraud investigations may be in-depth and extended.
Common Types of Healthcare Fraud Investigated by Authorities
There are a variety of potentially illicit actions that government investigates, including the following:
Billing for medically unnecessary services
This is an investigation into whether a healthcare provider billed for medical services that were either irrelevant to the patient’s treatment or minimally related to it.
Medicare and Medicaid only reimburse tests, procedures, imaging, or other medical services deemed necessary. Thus, in an investigation for medically unnecessary services, the investigators seek to determine the necessity of the medical procedure billed.
Kickback schemes are another common area of healthcare fraud investigation.
It is illegal for any medical facility or doctor to receive compensation (e.g. cash, equity, gifts, cross referrals, et cet.) from another doctor, medical facility, medical device manufacturer, pharmaceutical company, or any other person for referring patients, meeting specific quotas, prescribing a particular medication, or using a certain medical device. The principle behind anti-kickback legislation is that the providing of healthcare services must be driven by patient needs and not by any type of economic remuneration..
Billing for services not rendered
This type of fraud investigation involves reviewing the billing for services that were never rendered. It seeks to determine whether some providers submitted claim forms to Medicare/Medicaid for covered services or items that were not actually provided.
Investigators will look to determine whether providers created false records, signed charts, and submitted bills for tests or examinations to justify the bills.
An upcoding investigation determines whether a provider submitted a claim for services that were either never provided or billed for a more expensive service when an adequate, less expensive procedure was actually rendered and documented in the file.
Moreover, investigators will review whether a provider billed a simple office visit at a higher rate meant for a more complex visit.
Allowing nurses and staff to perform certain medical procedures
Medicare and Medicaid billing rules state that only a physician may perform particular procedures. Thus, government entities sometimes investigate to determine which member of the medical staff performed a particular procedure. The investigation attempts to determine whether non-physician staff performed a routine outpatient service that was then billed to the government insurer as performed by the physician.
Unbundling is the practice of billing for various tests or procedures required to be billed together separately to receive greater reimbursement. Investigations will seek to discover whether unbundling was performed and, if so, whether it was intentional or negligent.
As the name suggests, double billing happens when a provider submits claims multiple times even though the service or item was only provided once. An investigation that substantiates the existence of double billing usually results in the initiation of a civil enforcement proceeding. Only in cases involving knowing and intentional multiple billing for a single service would criminal prosecution be possible.
Misrepresenting non-covered treatments
This investigation focuses mostly in the specialty area of cosmetic surgery. For example, an investigation may seek to determine whether a medical practice or medical professional billed a non-covered cosmetic procedure such as a “nose job” as a deviated-septum repair to obtain insurance payments.
Penalties for Healthcare Fraud and Abuse
In response to the prevalence of healthcare fraud, Congress established certain acts as a federal criminal offenses through the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The HIPAA established a comprehensive national Healthcare Fraud and Abuse Control Program (HCFAC) to help detect suspicious activity and fight fraud committed against private and public health plans.
Committing a basic crime carries a federal prison term of up to 10 years and significant financial penalties.
Should a perpetrator’s fraudulent scheme result in the injury of an individual, the prison term can double to 20 years. Should it result in a patient’s death, the suspect can be sentenced to life in federal prison.
The False Claims Act and other regulatory legislation provide civil penalties for non-criminal healthcare fraud. Civil penalties vary, but may be extremely large. Additionally, there are provisions that allow barring of offenders from participation in programs and the potential loss of licences and practice privileges
How Can Serafini Law Office Help?
If you are being investigated for healthcare fraud or are facing healthcare fraud charges, the Serafini Law Office can provide you with the best representation possible.
Mr. Richard A. Serafini has 40 years of experience practicing law, and you can trust him to formulate an effective defense strategy to combat any potential civil or criminal charges that enforcement authorities may bring.
The Serafini Law Office currently offers legal services to the following cities and states: Miami, Fort Lauderdale, Boca Raton, West Palm Beach, Florida, Pennsylvania, and New York.
Contact us at (754) 223-4718 for a free and confidential consultation.