Understanding health care billing fraud

On Behalf of | Sep 4, 2020 | Criminal Defense |

In such a complex healthcare system, mistakes will naturally happen during the billing process. Sometimes billing errors are not all innocent and can escalate to healthcare fraud and abuse. Individuals might feel tempted to exploit the reimbursement system because of its complicated nature.

All medical professionals should learn how to identify and avoid healthcare billing fraud in their practices as it is a serious issue.

Examples of billing fraud

When healthcare providers intentionally manipulate the insurance coding and billing system to their advantage, they commit billing fraud. One example of billing fraud is upcoding. This fraudulent practice occurs when patients receive bills for services that are more expensive than what was actually provided. If a healthcare professional submits the same bill several times to the patient’s insurance company after only performing the procedure once, this also amounts to billing fraud.

Unbundling is a technique in which dishonest medical providers may also attempt to increase their profits. The practice becomes fraudulent when one bills each stage of a medical procedure as if it were a separate procedure rather than a bundle.

Protecting yourself against unintentional fraud

A provider can avoid medical coding errors in his or her practice by hiring full-trained, competent billing staff and outsourcing billing services. Additionally, implementing strict internal procedures will help detect claim issues. Examples of checkpoints before submission to insurance companies include external auditors and cross-checking forms.

Taking these extra precautions is beneficial as the consequences of billing fraud, whether intentional or not, are severe. Health care providers who bill fraudulently open themselves up to significant fines, loss of their professional licenses and criminal or civil penalties. Their entire practices could very well go out of business if the financial impact of these consequences are too great to survive.