Many hospitals and medical practices increase their revenue by accepting government insurance. Both Medicare and Medicaid can cover routine expenses and emergency medical costs.
However, the businesses and professionals that accept government insurance benefits have to conform to regulatory restrictions and uphold the terms of their contracts with the insurance program. Certain billing practices could lead to allegations of health care fraud that could have costly and career-damaging consequences for the professionals involved. All three practices mentioned below could lead to claims of health care fraud.
1. Upcoding or overcharging
Every different medical procedure and expense has a unique insurance billing code. Upcoding is the fraudulent practice of inputting a different billing code than the one that technically applies. Even if the different services involve the same type of professional, the same tools and the same amount of time, upcoding could lead to fraud allegations.
2. Unbundling
It is common practice to combine the costs for services typically provided simultaneously and to discount the amount charged for them. The practice of unbundling involves separating each expense and billing for them separately. Unbundling results in an overpayment of benefits and is a form of fraud.
3. Phantom billing
Sometimes, pharmacies submit billing requests for prescriptions that patients never collect. Other times, primary care providers might bill Medicare or Medicaid for appointments that patients missed. Phantom billing for services not rendered is fraud even if the medical practice has a clear policy on charging for canceled visits.
Fighting back against white-collar criminal charges, including health care fraud allegations, typically requires careful preparation. Professionals accused of inappropriate billing practices generally need support if they don’t want to accept a career-altering conviction.