There’s an expectation that those working in the medical sector should adhere to certain basic ethical standards. Health care professionals and certain support Personnel in administrative positions may require state-issued licenses to do their jobs. They also have to ensure that they comply with state and federal regulations.
Otherwise, they could be at risk of prosecution. Office managers, billing specialists and even insurance coding professionals are vulnerable to criminal prosecution if they take liberties related to insurance billing. Especially if questionable conduct involves government insurance programs such as Medicare or Medicaid, professionals could be at risk of federal prosecution for health care fraud.
In recent years, claims of phantom billing practices have resulted in numerous high-profile criminal cases. Health care professionals and administrative workers could be at risk of prosecution if they engage in phantom billing.
Billing regulations are clear
Both the law and the contracts signed with insurance programs outline when medical businesses can bill for services and how much they can charge. There are clear rules that establish that businesses can only bill for medical services actually provided to patients or prescriptions that they fill and take home.
Unfortunately, medical businesses lose money when patients don’t show up to appointments or when doctors call in prescriptions that patients never collect. They spend time preparing a prescription or allocate a professional’s time to the care of a patient.
Many medical practices have policies for addressing last-minute appointment cancellations and may charge a fee when people don’t attend their scheduled appointments. Phantom billing involves charging insurance companies for prescriptions that patients do not collect or appointments that they do not attend.
In some cases, these billing attempts may represent an effort to reduce operational losses or protect patients from a canceled appointment fee. In more egregious cases, billing specialists might completely fabricate appointments and prescriptions as a means of increasing the company’s revenue.
They may operate under the assumption that phantom billing is a victimless crime, as the patient doesn’t have any direct culpability. However, everyone who buys into a certain insurance pool or pays taxes may have to help cover the cost of phantom billing fraud.
Sometimes, the billing specialists accused of phantom billing are unaware that they have engaged in fraudulent practices because they don’t have direct interactions with care providers or patients. They may not know that the patient was a no-show. Other times, they may simply have followed the instructions of their employer based on the training that they received and may not realize that their actions could put them at risk of federal prosecution.
Learning more about the most common forms of health care fraud and those receiving priority consideration from regulators can help medical professionals avoid scenarios in which they are at risk of prosecution. Phantom billing may seem harmless but can have a ripple effect on a professional and numerous other people.