3 common forms of Medicare and Medicaid fraud to avoid

People in the healthcare sector may be more susceptible to white-collar criminal charges than those in many other professions. All it takes is improper training or the wrong mentality to put a professional at risk of breaking the law.

Those providing medical services, including doctors and physician assistants, could eventually face health care or insurance fraud allegations because of their record-keeping or medical practices. Professionals working as insurance coders or billing specialists could also be at risk of fraud charges, as could office managers at medical practices.

Seemingly reasonable billing habits can constitute health care fraud and might lead to charges against people who may only want to optimize revenue for an employer. What types of billing fraud do those in the medical sector need to watch for in particular?

1. Upcoding

Hospitals and medical practices generally negotiate specific reimbursement amounts for different procedures. In some cases, the amount of time invested, the materials used and the diagnosis could all fit with a different, more expensive treatment.

Upcoding is the practice of submitting an insurance claim for a more expensive procedure than the one actually performed. Upcoding may seem harmless, but it is one of the most common forms of health insurance fraud.

2. Unbundling

One of the ways that insurance companies and government insurance programs control healthcare costs is by combining certain billable expenses. A patient having a biopsy of a mole performed may require a physical procedure, local anesthetic and stitches.

By bundling those services together, insurance programs can keep costs a bit lower. Unbundling involves separating out each component of a medical procedure usually billed at a discounted rate to charge more.

3. Billing for missed appointments

Many medical offices charge a fee if patients don’t show up or cancel an appointment without adequate notice. Sometimes, patients cannot afford that fee and might ask the staff at the facility to bill their insurance anyway to avoid the fee.

Doing so may seem like a courtesy to the patient, but it puts the professional involved at risk. Those small choices, which a professional may make on their own or because of the training that they received, could ultimately lead to a federal prosecution for health insurance fraud.

Recognizing seemingly minor decisions that can lead to white-collar criminal charges can help people protect themselves. Those accused of fraudulent billing activity may need help preparing to fight the allegations at trial.