What is Healthcare Fraud?

Healthcare fraud is a broad-brush term for fraud committed in the healthcare industry, typically committed by overbilling patients, private insurers, or government insurers such as Medicare. Healthcare fraud can be committed by actual healthcare providers who bill for fake or unnecessary services, or by other individuals who fake or otherwise illegally obtain physician credentials in order to charge patients or insurers for unneeded services or equipment.

A scrupulous healthcare provider with proper policies and procedures in place can avoid charges of healthcare fraud. Consult with a knowledgeable health care fraud defense attorney to make sure that your policies are sound and that you are not inadvertently violating any state or federal healthcare fraud laws, or if you are facing any investigation or prosecution for healthcare fraud.

Common Types of Healthcare Fraud

These are a few of the more common fraud schemes according to the FBI and the National Health Care Anti-Fraud Association.

• Medical equipment fraud. This scheme involves medical equipment manufacturers offering “free” products to individuals. They then charge insurers for products that were not needed or often not even delivered.
• “Rolling Lab” schemes. Rolling lab schemes involve administering unnecessary and sometimes fake tests to people at health clubs, retirement homes, shopping malls, or medical clinics, and then billing insurance companies or Medicare for the tests. The individuals being tested may be complicit or unwitting.
• Billing for services not performed. Customers or providers will bill insurers for services that were not actually rendered, often by altering existing bills or submitting fake bills. Often the perpetrators will use actual patient information, sometimes obtained through identify theft.
• “Upcoding.” Upcoding involves billing for more expensive services than those actually performed. This will often involve inflating the patient diagnosis to something more serious in order to trigger the need to perform a more expensive test.
• Performing medically unnecessary services. Physicians will perform tests solely for the purpose of generating insurance payments, with or without the knowledge of the patients.
• Misrepresenting non-covered treatments as medically necessary. Healthcare providers will perform a non-covered procedure and then bill insurers as if it were medically necessary; for example, billing an unnecessary cosmetic “nose job” as if it were a deviated septum repair.
• Medicare fraud. Medicare fraud can take many forms, including the schemes described above. Medicare fraud involves any scheme designed to overbill Medicare for fake, inflated, or unnecessary services. Medicare schemes often target senior citizens, such as by offering them free medical products in exchange for their medical numbers. Perpetrators will fake physician signatures or bribe doctors into signing off on bills for merchandise or services that were unnecessary or not ordered or performed, and then send the bill to Medicare.

While many of these fraud schemes are perpetrated deliberately and maliciously, it may be easier than it seems to accidentally up-code or bill for the wrong procedures. The federal government tends not to appreciate the difference. A knowledgeable healthcare fraud defense attorney can help you keep your practice safe and legal and avoid any unnecessary brushes with law enforcement.

Practical and Effective Advice and Representation in California Healthcare Law

If you’re a California healthcare provider who needs assistance with matters pertaining to your practice, your licensing, or any other legal issue, get seasoned and effective help by contacting a dedicated Los Angeles healthcare lawyer at the Law Offices of Art Kalantar for a free consultation in Los Angeles or statewide at 310-773-0001.