A one-off billing mistake is not usually criminal healthcare fraud. But when the same errors keep happening, federal and state regulators may view them as a serious billing problem. In Arkansas, practices that bill Medicare, TRICARE or Medicaid may face review from federal and state agencies, including the Department of Justice (DOJ), the Office of Inspector General for the Department of Health and Human Services (HHS-OIG) and the state Medicaid agency or fraud investigators.
Intent versus reckless disregard
The key difference between a routine mistake and a fraudulent claim is often the provider’s intent and pattern of billing behavior:
- Criminal healthcare fraud: This generally requires proof that a provider knowingly and willfully participated in a scheme to defraud a healthcare program. Simple typos or coding mistakes usually do not meet that standard.
- Civil false claims laws: These claims may not require proof of specific intent. A provider can still face liability if the record shows actual knowledge, deliberate ignorance or reckless disregard.
If an Arkansas clinic ignores audit warnings, fails to train billing staff or continues using incorrect billing codes after notice, regulators may argue that the practice showed reckless disregard.
Common errors that can trigger investigations
Data tools often flag billing patterns that may point to fraud. Some of the most common red flags include:
- Upcoding: Billing for a higher level of service than the one provided or documented.
- Unbundling: Billing each step separately instead of using one combined code.
- Billing for services not rendered: Submitting claims for missed appointments or for care that was not properly provided.
A single billing mistake may lead to a repayment request. Repeated errors can sometimes lead to more serious penalties, including fines, treble damages and exclusion from federal programs, depending on the facts and the law.
Steps to reduce risk
If you find ongoing billing errors, a compliance program and prompt self-disclosure may help show good faith and may reduce risk in some situations. A healthcare attorney can help you decide what to do next.