Medical Billing Fraud

The concerted efforts of the the Federal Bureau of Investigation (“FBI”), the Drug Enforcement Administration (“DEA”), the New York Department of Health, the Health and Human Services Department, the Bureau of Narcotic Enforcement, the Office of Inspector General, the Worker’s Compensation Board, Excellus Special Investigations Unit, Safeguard Services and MVP Health Care, Special Investigations Unit led to the conviction on May 22, 2015, of a Central New York Doctor for sending false and fraudulent billings to Medicare. The doctor, who committed and pled guilty to the crime of medical billing fraud, was sentenced to an 18-month prison term, three years of supervised release and restitution of $84,265.11 to Medicare. According to the Federal Bureau of Investigation (FBI), the agency responsible in exposing and investigating healthcare fraud in federal and private insurance programs, healthcare fraud costs the U.S. tens of billions of dollars annually. This is one criminal activity that continues to threaten the financial aspect of Medicaid and Medicare, two government programs designed to provide medical and health-related services to particular groups of people in the US. Healthcare fraud is committed through different ways:

  • Filing claims for treatments that are actually not provided;
  • Making claims for illnesses or injuries that do not really exist;
  • Fabricating names when filing insurance claims;
  • Over-charging the government for treatments provided to patients;
  • Filing claims for non-existent medical supplies; and,
  • Resorting to “rolling lab schemes,” wherein Medicare and insurance companies are billed for needless and, sometimes, bogus tests provided to people in shopping malls, health club patrons, and/or retirement homes residents; to make the tests appear legitimate, signatures of physicians are often faked.

Though majority of healthcare providers are honest, their integrity and reputation are easily marred due to the greed of a few groups and erring medical professionals. Add this greed to the complexity of the medical billing system, which causes some medical providers and organizations to occasionally commit mistakes when coding the services they provide to patients, and commission of fraud becomes easier, but detection, much harder. This circumstance has made authorities more determined in pursuing and prosecuting fraudulent activities with much more aggressiveness, often resulting to honest healthcare providers, hospitals, clinical laboratories, medical equipment suppliers, hospices and home health agencies being subjected to fraud investigations. In certain situations, authorities exaggerate the extent of the fraudulent acts of those that they arrest, unmindful of the damaging effects that an exaggerated accusation can cause these healthcare providers. Due to the gravity of the crime of medical fraud, anyone accused ought to consider speak with a medical fraud attorney, who may be able to help assessing what will need to be done for his/her case.

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