Healthcare Billing Fraud

Health Care Billing Fraud

The National Health Care Anti-Fraud Association estimates that healthcare fraud costs the United States approximately $68 billion annually. Oversight, regulations, and investigations of fraudulent billing for medical procedures and services have become a nightmare in our country; not only for investigators but also for medical professionals and the general public alike. When fraudulent claims are paid out, that disbursement of monies comes from inflated costs of medical services rendered, which results in higher premiums and costs for everyone. This fraud is a major factor in the American healthcare crisis we face today.

Federal investigators are greatly challenged with combatting healthcare billing fraud. With so many claims being submitted on a daily basis, it is nearly impossible to evaluate every invoice submitted by healthcare professionals, facilities, and Medicare/Medicaid providers. This alone opens the door to an astounding amount of healthcare fraudulent billing.

The Costs Of Healthcare Billing Fraud

Healthcare billing fraud has become so common that it is an almost acceptable standard of practice among many in the medical profession. Fraud in the chiropractic field is especially rampant. In 1972, the US Congress made chiropractors eligible to receive reimbursement under Medicare Part B. This means a chiropractor may opt to treat a patient long after the treatment is no longer helpful or necessary. This is frequent in accident cases, since any settlements will ultimately be based mainly on the length of time necessary for the victim to recover completely from the injuries incurred by an accident.

Healthcare billing fraud incurs significant expenses across the board. According to a recent study, more than 80% of all Medicare payments for services in chiropractic offices cost the government nearly $360 million in unnecessary care for patients. In the year 2010, according to the Office of Management and Budget, fraudulent payments of almost $50 billion were paid out to medical professionals. When these billing sums are paid, the disbursement of monies comes from higher costs for the provider; in turn, this results in higher costs for all members of the group.

In a recent case, a physician charged with more than one hundred false procedures had to pay $1 million to settle violations of the False Claims Act. But a physician convicted of healthcare billing fraudulent pays an even higher cost. The guilty verdict proves detrimental to the physician’s career and reputation and may cause the physician to lose his license to practice and/or lose patients.

Methods Of Healthcare Billing Fraud

Billing Fraud for medical procedures or services occurs in numerous ways.

Unintentional mistakes in billing and/or coding, usually in transcription, happen frequently. Some medical professionals believe they are safe if they claim an honest mistake in billing. However, even if billing is made via clerical error, federal investigators consider it fraudulent and may charge the medical professional with a crime.

Coding errors in Healthcare

The method of assigning a code number to medical procedures and diagnoses — is another type of healthcare billing fraudulent. Regardless of whether a billing mistake is intentional or not, it is common for billing to use the wrong code for a procedure. These codes have become universal in the US and are used by physicians, private health insurance providers, worker’s compensation providers, government health programs and other organizations. These codes are often taken by a secretary from a physician’s notes, along with lab reports and other results.


In addition to submitting an incorrect billing code, medical professionals may submit a fraudulent healthcare bill through the use of upcoding. Upcoding refers to such tactics as fraudulently claiming a longer time for a procedure, claiming the use of equipment that was never used, claiming more assistance than was used, billing for procedures that never took place, creating billing for therapy that was never performed. Sometimes a physician submits a claim for a fictitious procedure. The individual who follows the doctor’s notes in billing would then have no knowledge of any fraud and simply bill accordingly.

Another method of defrauding providers is called unbundling. For instance, if a medical professional orders a series of blood tests, it is considered a bundle and should be coded as such. To commit fraud, this code would later be ignored, each of the blood tests would get separated and the code for each would be used separately, thus increasing the medical professional’s revenue.

Hospitals are also tempted by the ease of unnecessary and fraudulent actions. In addition to the practice of upcoding, they may admit patients to a hospital when it is not necessary, and may even receive kickbacks for doctor referrals and/or medical tests such as MRIs or sonograms. Other common violations include claiming payment for services and procedures not provided and/or unnecessary.

Hire A Medical Billing Fraudulent Attorney

If you’re a physician and you are charged with healthcare billing fraudulent, your first move should be to consult a healthcare billing lawyer. These lawyers specialize in handling charges of healthcare fraud, medical billing fraud, and coding fraud and know how to deal with federal investigators. An experienced attorney may be able to have a charge of medical billing fraud dismissed without your ever having to appear in court and without any publicity.

If you know a medical professional who has committed healthcare billing fraudulent, under the qui tam provision of the False Claims Act, it is your responsibility to report the crime. Failure to do so may later cause you to get charged as an accessory to the crime.

Reputable medical professionals must remain on the lookout for accidental healthcare billing fraud. Because of the tendency to mislabel coding or other procedures by assistants — some with limited experience and/or training — any medical professional may potentially find themselves caught in the crosshairs of billing fraud, and may have a difficult time proving themselves innocent of any charges. A good defense attorney is the only recourse. Call 888-402-4054 and speak with a healthcare billing fraud lawyer today.