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Health care fraud usually involves providers, not patients

On Behalf of | Jan 3, 2024 | Federal Criminal Defense

Media discussions of healthcare fraud often focus on individuals receiving benefits they do not deserve. Particularly when people use government insurance programs, like Medicaid, there are often concerns that they may not technically deserve the benefits they received.

However, according to federal information about health care fraud, the vast majority of financial losses related to healthcare fraud come from health care providers, not the patients they treat. Those working at hospitals and other medical establishments may engage in improper billing practices that cost insurance companies or taxpayers money.

Billing specialists and actual medical workers could end up implicated in a health care fraud case. What behaviors might lead to allegations of business health care fraud?

Billing for services not rendered

One of the most common and egregious forms of health care fraud is the choice to bill for an appointment that didn’t occur or treatment not provided during an appointment. Such practices can increase the profit margins for struggling medical businesses. Some health care providers may view this as a victimless crime, but the reality is that everyone paying into an insurance system loses out when providers charge for services that they did not render. Patients who receive statements from their insurance providers may discover appointments that they did not attend and may bring them to the attention of regulatory authorities.

Manipulating the billing process

Billing falsely for services not rendered is an obvious issue and a high-risk behavior that most professionals realize they should avoid. However, billing specialists and others in the medical industry may use other, less obviously illegal behaviors to increase revenue. They might upcode or charge for a more expensive service than the one actually provided to a patient. They might unbundle charges to bypass a discounted pricing agreement and charge more for services rendered to a patient.

There are a host of ways that health care providers and the support staff working in medical offices might violate agreements with insurance companies or the law. Even hourly workers in the billing department who do not directly profit from such schemes could be subject to criminal prosecution if regulatory authorities discover improper billing practices.

As a result, being able to recognize signs of health care fraud could help people avoid professional mistakes that could harm their careers or lead to their prosecution.