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Avoiding types of fraud to protect your medical license

On Behalf of | Jul 19, 2023 | Professional Licensing Defense

In California, medical doctors are legally obligated to follow the Healthcare Fraud Penal Code 550(a). This law prohibits healthcare providers or insurers from knowingly submitting false claims in exchange for financial gain. This law is punishable by criminal charges, fines, license revocation and imprisonment.

Types of healthcare fraud

Many types of healthcare fraud can result in severe outcomes for medical doctors. To protect their professional licenses and avoid engaging in fraudulent activities, medical doctors must stay aware of common types of healthcare fraud, including:

  • Upcoding: Upcoding occurs when a physician charges the patient for a more expensive service than the physician provided. Pricing more than appropriate is illegal and doctors must price at an appropriate rate for their services.
  • Billing fraud: Double billing and phantom billing are two types of billing fraud. Double billing is when a doctor sends multiple claims for the same service. This results in a patient or their insurance company paying more than necessary. Phantom billing is when a healthcare provider charges for services or supplies the patient never received.
  • Kickbacks: Kickbacks refer to receiving payment in exchange for giving or receiving referrals. All federal healthcare programs, including Medicare and Medicaid, are covered under the Anti-Kickback law in California.

Consequences of fraud

In California, doctors who engage in dishonest billing may be charged with a crime and go to jail for five to 10 years. They may also pay fines ranging from $1,000 to $50,000, depending on how much money they are accused of taking.

Accurate billing practices are crucial for doctors, but the complex and frustrating healthcare system can make it difficult to avoid mistakes. Those who are overworked and under pressure may be particularly susceptible to errors. However, legal remedies may be available to protect their medical licenses and reputations if mistakes do occur.