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What healthcare workers should know about medical billing fraud

On Behalf of | Jun 9, 2021 | Employment Law |

As the business side of a medical enterprise, proper billing keeps the doors open. Occasionally, billing practices are manipulated to procure payment for unperformed, unnecessary treatment, or upcoded procedures. If you notice this practice at your workplace, you should know that this is a form of healthcare fraud.

Just because your workplace does it that way doesn’t mean it’s legal

Last week we wrote about the history of the False Claims Act (FCA) and how it allows whistleblowers the opportunity to stop unscrupulous practices and obtain a share of the government’s recovery. However, healthcare fraud is difficult to identify if you do not know what to look for, such as:

  • Upcoding: Charging for a more expensive type of visit or procedure when patients come in, such as coding a routine check-up as a sick visit.
  • Unnecessary tests: When healthcare providers order tests simply to run the test, not with the intention of learning something about the patient or when the testing is split to enhance billing
  • Billing for unperformed treatment: Finding a history of procedures that the physician never performed for a patient.
  • Receiving special treatment from other service providers: Practices often work together, but those relationships might be an illegal kickback arrangement.

Newer employees and those lower in the organizational hierarchy may find themselves discouraged from looking into such irregularities and concerned about HIPAA violations. However, the FCA encourages possible whistleblowers by offering them employment protections and potential rewards, and making an exception to HIPAA protections.  Call for legal advice to navigate around HIPAA and data collection.

False claims cost billions in public funds

Last year, the US recovered $2.2 billion as a part of qui tam lawsuits. The year before, the figure was $1.6 billion. Considering the increasing amount of fraud found each year, this is simply the tip of the iceberg.

In cases of Medicare and Medicaid fraud, it falls to individuals with scruples to stand up and take steps to end deceptive billing practices.