Understanding what constitutes fraud in the medical world

The health care system in the United States is notoriously complex. This can lead to care providers, medical corporations and billing specialists facing allegations of health care fraud. These charges can and do lead to criminal and professional penalties.

There are several types of health care fraud that medical professionals can face. Understanding what constitutes medical fraud and the potential consequences can help you do your job to the best of your ability without incurring any legal risk.

What is medical fraud? 

In Florida, medical fraud ultimately boils down to one of two actions:

• Paying those who should not receive payment
• Overcharging patients for medical services

It is understandable for doctors and other health care providers to occasionally make these mistakes. For one of these actions to constitute medical fraud, the individual must have knowingly sent improper payments or overcharged a patient.

Common alleged fraudulent actions 

While there are a broad range of actions that may lead prosecutors to pursue criminal charges, the follow actions are often associated with allegations of medical fraud:

• Billing for unperformed procedures: A medical practice may insert one or more extra services when billing an insurance company that the patient did not receive. Upgraded treatments may also draw scrutiny from those investigating possible instances of fraud. The billing practices of medical centers are more likely to come into question during complex procedures where medical centers typically bundle multiple services together.
• Double billing: A medical provider may bill an insurance company twice for a single treatment or service, whether through the same code or by using two separate codes.
• Performing unnecessary procedures: Health care professionals try to take the necessary precautions to keep their patients safe. However, insurers may try to argue that the patient did not need the procedure.

Medical fraud charges could impact your career

The criminal charges that relate to medical fraud will vary, depending on the nature of the fraud. Those paying for the fraud, whether it is a patient, an insurance company, or the government via Medicare or Medicaid, will also impact the potential charges. In cases involving government insurance programs, there is the potential for federal charges.

Criminal charges can impact your ability to retain your license if you work as a nurse, doctor or physician’s assistant. Many governing boards take a firm stance against criminal activity, especially if it relates to a job in the medical field. Those who work in the medical field providing care or managing billing should remain vigilant to avoid involvement with any kind of potential fraud.