Federal prosecutors are often aggressive when addressing alleged health care fraud. Health care fraud drives up the costs of private insurance and has an impact on taxpayers as well. When medical companies or professionals engage in fraudulent billing practices, other parties pay the price for their misconduct.
In some scenarios, such as when physicians recommend and then perform unnecessary treatment, they may derive direct financial benefit from behavior that can cause verifiable harm to others. However, not all federal charges alleging acts of health care fraud involve actual health care professionals. Frequently, charges target support professionals, including coding and billing professionals, who may have submitted claims to insurance companies. Some health care support professionals learn the hard way that they do not have to play a direct role in fraud for the government to hold them accountable.
Improper billing is actionable regardless of profit
There are numerous clear rules in place regarding insurance billing. Typically, medical practices and hospitals have to abide by the unique rules implemented by different insurance companies or programs. They have to adhere to discounted rates for bundled services and otherwise comply with standard billing practices.
Billing for services not rendered, upcoding to bill for a more expensive procedure or separating discounted services out by unbundling them can potentially lead to increased revenue for the medical practice or hospital. The worker performing those steps may not receive any profit sharing or direct financial incentive for their behavior.
Direct financial gain is not a necessary component of successful health care fraud charges. Instead, prosecutors only need to establish that an individual voluntarily played a role in a scheme to over-bill for the services provided by the company.
Professionals facing federal criminal charges due to their involvement in an alleged insurance fraud case may need help protecting themselves. There are several possible solutions available to those facing fraud-related charges. For example, they might be able to use information about company training practices to raise questions about the situation.
Every federal health care fraud case is unique, and the people facing accusations often need help evaluating their options. Discussing company practices and pending charges can help support professionals like billing specialists or insurance coders protect themselves from the worst-case scenarios.