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Why are you suspected of health care fraud?

When you decided to become a doctor, you agreed to do no harm to your patients. You committed yourself to helping Greenville residents recover from injuries and illnesses and get back to a healthy and normal life. If you can’t do that, you provide them with the best care possible in order to manage their ailments.

While you expect to receive payment for your services, you may not directly involve yourself in how that happens. Instead, you rely on staff you personally chose in order to handle the “business” aspects of your practice. Then, one day, you discover that you are under investigation for health care fraud. How did this happen?

What exactly are government officials accusing you of doing?

When it comes to health care fraud, the following are considered the most common ways it occurs, according to the National Health Care Anti-Fraud Association:

  • Officials may accuse you of billing for each step in a procedure instead of billing for one procedure, referred to as “unbundling” in the health care industry.
  • You face accusations of billing a patient above the copay for procedures fully covered or prepaid for under a managed care contract.
  • Officials may accuse you of waiving deductibles and copays, and then turning around and overbilling insurance companies.
  • You may face allegations of billing a patient or insurer for a more expensive procedure than you performed, referred to as “upcoding” in the industry.
  • Officials may accuse you of billing an insurer or patient for procedures that someone never even performed.
  • You may face suspicion of claiming a procedure is medically necessary when it isn’t in order to bill a patient’s insurance company.
  • Officials may say that you performed procedures that were not medically necessary in order to obtain money from an insurance company. Going hand in hand with this accusation is one that you falsified patients’ diagnoses in order to perform those procedures.

You could also face accusations of health care fraud if officials suspect you of accepting kickbacks for patient referrals. After years of dutifully serving your patients, you may find it abhorrent and shocking that anyone would accuse you of any of the above. You may believe that the evidence will clear your name and you don’t need to do anything.

Taking this stance on the issue would more than likely be a mistake. You have rights, and you need to protect them. In addition, you need someone to advocate for you with authorities, which could help resolve the matter before it really begins. You would greatly benefit from discussing your situation with an experienced white-collar crime attorney before it’s too late.


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