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Creative billing in a medical practice can lead to criminal charges

Creative billing in a medical practice can lead to criminal charges

On Behalf of | Jul 14, 2021 | Federal Criminal Defense

People think that medicine is a lucrative industry, but many small medical practices operate with a very thin profit margin. Between staffing costs and facility expenses, practices may struggle to remain profitable. 

If you work as a billing specialist or an office assistant at a medical practice, part of your job may involve entering the billing codes for patient procedures. You review the medical records and then actually submit the billing request to the insurance provider, whether it is a private company or a government insurance program. 

If you get a little creative with your billing practices to try to help your employer make a little more money, you could wind up charged with health care fraud even if you don’t profit directly from your billing activities.

Upcoding is against the law

There are numerous billing codes that all describe closely related medical procedures. Those billing an insurance company may feel tempted to bill for a more expensive procedure that treats the same condition. However, charging for procedures other than the one performed to seek more compensation is upcoding, and it is a known form of fraud. 

Unbundling is also an insurance law violation

Insurance companies spend a lot of time and effort negotiating cost-saving measures with the professionals who accept their coverage. Bundling procedures together for a slightly lower price is a common practice. If your employer has agreed to bundle services with an insurance provider, it is illegal to unbundle and bill for those individual procedures or treatments separately. 

Understanding when creative accounting and billing practices actually become health care fraud can help protect you from intentionally violating the law. If you have been charged (or suspect you will be), it would be wise to speak with an experienced defense attorney soon.


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