What is Healthcare Fraud?

Fraud is a serious challenge facing healthcare organizations today. An accusation of healthcare fraud can cause irreversible damage to a medical professional’s career and reputation and lead to hefty fines and even prosecution. Sometimes this accusation is made by someone called a “whistleblower”, who might even work for them. This person tells legal teams about the accused person and their actions, via a whistleblower lawyer, and ultimately then gets protection if the case is to go any further. All healthcare professionals must be aware of healthcare fraud and follow best practices to avoid potential compliance issues. With this in mind, here are the key things you need to know about healthcare fraud:

What does healthcare fraud look like?

Healthcare fraud is a serious crime that costs the US billions of dollars each year. Most incidents of healthcare fraud are performed by organized crime groups, although a small percentage of fraud cases are the result of dishonest medical professionals. Because of this, many hospitals will use a third-party billing company, like Precision Medical Billing, to collect a medical debt. By using a company separate from the hospital itself, the chances of fraud should in theory be reduced. Broadly speaking, healthcare fraud involves submitting fraudulent medical insurance claims for financial gain. Here are some of the most common examples of healthcare fraud:

  • Billing for medical services or treatment that never took place.
  • Billing for medical services or treatment at a higher rate than those that took place.
  • Completing unnecessary medical services to generate insurance payments.
  • Submitting insurance claims for patients that were never seen or treated.
  • Overcharging patients for medical services or procedures.

What is a healthcare fraud investigation?

As mentioned, healthcare fraud costs the nation huge amounts of money each year, and the government invests heavily in uncovering and preventing healthcare fraud. A healthcare fraud investigation is launched when fraud is suspected. The investigation can be focused on an individual or an organization as a whole. An investigation may be started if an analyst notices a suspicious insurance claim pattern, or a healthcare professional files a report of suspected healthcare fraud within their workplace. If you are investigated for healthcare fraud, you will receive a letter from a fraud investigator and may be asked to provide certain documentation to assist the investigation. It is always advisable to seek professional legal advice if you are being investigated for healthcare fraud. You can find further advice on your legal rights during a healthcare fraud investigation by visiting Healthcarefraudgroup.com.

What are the penalties for healthcare fraud?

The penalties of healthcare fraud depend upon the severity of the case and the outcome of the investigation. Healthcare professionals accused of submitting false insurance claims often have their medical licenses suspended or revoked. They may also face fines and be forced to recoup fraudulent payments. Some individuals and organizations found guilty of healthcare fraud even face criminal proceedings and incarceration.

How can I prevent healthcare fraud?

The good news is, there are various ways for healthcare providers to help prevent healthcare fraud and protect themselves from compliance issues. In particular, healthcare organizations must enforce a detailed compliance program and adopt a zero-tolerance approach when it comes to healthcare fraud. To avoid investigations, healthcare facilities must maintain accurate records and avoid inaccuracies that could raise suspicions of fraud. Various technology and software can be utilized to minimize human error and notify managers of any suspicious billing patterns. Healthcare staff should also receive training on potential risks and be told to report suspected fraudulent behavior to the correct authorities immediately.