If you were to ask the average person about Medicare or Medicaid fraud, as well as any form of medical insurance fraud, they will most likely talk to you about individuals who shouldn’t have benefits getting medical coverage. While it is true that individuals can commit Medicare or Medicaid fraud, those cases account for a tiny fraction of the total government insurance fraud that occurs every year.
The vast majority of fraud-related Medicare and Medicaid losses stem from medical providers, not from patients. Whether you work as a nurse, a physician, a physician’s assistant or a billing professional, you could be at risk of facing white collar criminal charges if you get involved in medical insurance billing fraud.
Why does provider insurance fraud happen?
Medical providers offer a service to the community that they then bill insurance companies for. They receive reimbursement for their services and pass along uncovered expenses, such as coinsurance, co-pays or deductibles, to the patients themselves. A medical practice can be a very lucrative business, but for some people, their actual earnings don’t seem like enough.
Medical providers or their practice managers could decide that they want to make more money from the patients they already have. They may then engage in fraudulent billing practices that help pad their pockets while depleting public coffers. A medical practice could bill for patients they have never seen or procedures they never performed. However, these kinds of fraud are often the easiest to prove, so some people engaged in Medicare or Medicaid fraud will go even further.
What are the most common forms of medical insurance fraud?
There have been cases of physicians or even dentists diagnosing conditions that did not exist and performing completely unnecessary medical procedures in order to bill for their time. In some cases, insurance fraud could look like a medical provider choosing the most expensive treatment when a more affordable option would serve the patient just as well.
Other times, physicians or their billing specialists will intentionally unbundle a discounted service. Common procedures often involve multiple different billable services, including medication, treatment and even a hospital room. Insurance providers negotiate reduced rates for bundled services. Intentionally billing for each separate charge when a bundled charge would have a lower reimbursement rate is another common form of fraud.
You don’t have to profit from the fraud to be guilty of it
Medical insurance billing fraud often primarily benefits the physicians and practice managers involved. The people taking the most active role, such as the billing professionals, may never see a cent of the increased income that comes into the practice through fraudulent billing. Unfortunately, simply choosing not to speak up makes you an accessory to the crime, if not part of a broader conspiracy.
There are rules in place that allow medical employees to serve as whistleblowers in cases of fraud. To incentivize workers to potentially risk their employment or face retaliation if they get caught reporting misbehavior by their employers, the government often chooses to allocate a portion of the fraudulent activity reported to the person making the report. You can bring a qui tam complaint on behalf of the government against a company, which may entitle you to a financial reward.