What Is Healthcare Fraud?

 Posted on July 03, 2019 in White Collar Crimes

By Attorney Tom Brown

When a business faces accusations of healthcare fraud, this can have a massive impact on its bottom line, since in addition to facing fines and other consequences related to criminal charges, its reputation in the community is also likely to suffer. This type of fraud can affect consumers, providers, and insurers, and it can cause the costs of everyone’s healthcare benefits to rise. Because of these negative effects, these crimes are taken very seriously by law enforcement officials, and those who have been accused of healthcare fraud should be sure to understand the charges and the potential consequences. 

What Does Healthcare Fraud Look Like in Action?

Healthcare fraud occurs when false or misleading information is intentionally submitted in order to determine the amount to be charged for healthcare benefits that a person can receive. This definition covers a wide variety of actions in the real world. Some examples include:

1. False billing: A provider may bill for services that never happened or for the incorrect procedure. This can be a way for the provider to earn additional money or for someone committing identity theft to fabricate an entire claim. In some cases, a patient’s insurance company may be charged for a procedure that is more expensive than the actual procedure that was performed.
2. Unnecessary procedures: Some medical professionals may perform unnecessary treatments or services in order to generate higher revenue in insurance payments.
3. Misrepresentation: Medical professionals have been known to misrepresent non-covered treatments in order to try to have a procedure covered by insurance. This is typically done with cosmetic procedures, such as nose jobs that are billed as “deviated septum repairs.” 
4. Unbundling: A provider may attempt to charge a consumer for each stage of a procedure rather than the procedure as a whole. Unbundling increases the cost of the service, allowing the provider to collect more payment for the same treatment.
5. Incorrect Charges: Lying to a patient about the amount being covered by insurance and billing them more than the co-pay amount is a tactic that may be used to cover up additional charges. The opposite may also occur; co-pays or deductible charges may be waived, causing the insurance provider to be over-billed for the medical service.
6. Kickbacks: This occurs if a healthcare provider accepts any rewards for receiving patient referrals. 

Contact a Milwaukee County Healthcare Fraud Defense Attorney

If your business has been accused of healthcare fraud, you may face severe consequences. At Gimbel, Reilly, Guerin & Brown, LLP we understand that not all accusations are true, and we can help your business defend against criminal charges that may affect your reputation, your medical license, and your bottom line. If you have been charged with healthcare fraud, contact our Milwaukee, WI white collar crime defense attorneys at 414-271-1440 to set up a consultation.

Sources:

https://www.cigna.com/reportfraud/

https://www.nhcaa.org/news/what-does-health-care-fraud-look-like.aspx