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Understanding what health care fraud is

When it comes to heath care fraud, it is thought to involve individuals who knowingly engage in deceptive practices with the goal of receiving unauthorized benefits. Health care providers found to have engaged in abuse or fraud can face administrative sanctions, civil, and even criminal penalties, under various state and federal laws.

Such sanctions and penalties can include being barred from participating in federal health care programs, including Medicaid. Additional consequences can include monetary fines and possibly even prison.

The Centers for Medicare and Medicaid Services recommends that health care providers become familiar with common waste, abuse, and fraud practices to be able to properly identify and report potential violations of laws. Such crimes that fall under this umbrella include medical identity theft, billing for unnecessary services or for items a patient was not furnished with, upcoding, unbundling, and kickbacks.

To better understand what these crimes entail, medical identity theft occurs when a person's medical information is used to obtain services, funds, or health care goods unlawfully. This can be done by utilizing a patient's or provider's information to bill public or private payers for medical goods or services obtained fraudulently.

As an example of this, a physician could have one's identification stolen to fill prescriptions or to refer patients for needless, non-essential services. With that in mind, It's important to note that any services provided must be medically necessary under Section 1902(a)(30)(A) of the Social Security Act in order to bill for them.

Upcoding has to do with services being billed at a higher rate than what was necessary for the actual service provided, such as an electric wheelchair being billed for, yet the patient was given a manual one. Unbundling has to do with billing separately for tests and procedures at maximum cost as opposed to them being bundled together at a reduced rate.

Kickbacks involve receiving some sort of financial incentive or compensation in exchange for providing federal health care services. Doctors taking advantage of the fact that they would qualify for referral fee for sending a patient to a specific provider would be an example of this.

If you or someone you know has been charged with a federal offense such as health care fraud, an experienced Orange County, California, white collar crime attorney can provide guidance in your legal matter.

Source: Centers for Medicare & Medicaid Services, " Common types of health care fraud," accessed March 07, 2017

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