Seeing enough patients is a key aspect of financial solvency as a physician. Doctors often have dozens, if not hundreds, of patients under their direct care when they work as primary care physicians or out of a medical office.
Medical facilities that accept Medicare and Medicaid have access to a much bigger pool of potential patients, but they are also subject to more oversight. Federal regulatory agencies and Ohio state authorities look aggressively for warning signs of provider insurance fraud.
When there are discrepancies between the treatment a patient receives and the invoices their health care provider submits, criminal prosecution could result. The physicians themselves and their support staff could be at risk of Medicaid or Medicare fraud charges because of company billing practices.
What kinds of behaviors might lead to allegations of government insurance fraud?
Improperly billing for services rendered
When a patient comes in for a simple outpatient procedure, there will be an approved reimbursement rate for those services. Your office should record the exact treatment provided and then bill for those services specifically.
When someone changes the billing code to a similar but more expensive procedure, that is fraud. If a worker takes multiple services traditionally combined for a discounted billing price and unbundles them to charge for them separately, that can be a form of insurance fraud as well.
Billing for services not rendered
Your office may impose a same-day cancellation fee for patients who do not attend their appointments. The reason is not to punish them but rather to prevent a loss of revenue, as you cannot bill for the time you committed to a patient who did not arrive.
It is insurance fraud to bill for appointments that did not occur. It is also insurance fraud to add extra charges to an appointment that did occur in the hope of receiving more payment. Subjecting patients to treatments they don’t require to bill for them is another form of fraud that comes with a secondary layer of criminal consequences because of the misconduct toward the patients.
Realizing when billing practices may cross the line into prosecutable offenses could help you and the people working at your company avoid white-collar criminal charges.
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