Allegations of fraud are among the most common criminal charges brought against those working in the health care sector. Inappropriate billing practices can diminish the profit margins of private insurance providers. If health care providers accept Medicare or Medicaid, fraudulent billing practices have a negative impact on these government insurance programs and taxpayers by extension.
Those working in the medical field, including physicians and professionals providing support services in medical offices, need to be aware of what type of conduct could lead to billing fraud allegations. Phantom billing claims at medical practices and pharmacies are a common source of fraud allegations.
There are rules about medical billing
Scheduling an appointment with each patient allows a medical practice to operate efficiently. The people handling scheduling can maximize the number of appointments that medical professionals have per day.
Unfortunately, last-minute cancellations can disrupt the schedule for the office and diminish profitability. Many medical offices have cancellation policies that impose a fee of $100 or even more on patients who do not attend their scheduled appointments. If a patient does not attend their appointment, they have to cover that fee with their own capital.
The medical practice cannot bill an insurance provider for an appointment that did not happen. Similarly, pharmacies cannot submit billing claims for prescriptions that people did not ultimately receive. Phantom billing entails submitting an insurance reimbursement claim for a prescription that a patient did not receive or an appointment that they did not attend.
Small choices can have big consequences
Office managers and billing specialists are among those at risk of prosecution over billing for phantom prescriptions or phantom appointments. If regulatory officials auditing government insurance programs or private insurance companies discover phantom billing, an investigation may occur. In some cases, patients report concerns when they receive statements from their insurance companies that trigger investigations.
The people involved in inappropriate billing practices could face criminal charges. In addition to criminal penalties that vary depending on the total amount billed, those accused of health care fraud could also face orders of restitution and a loss of professional licensing. Professionals in the health care sector need to be proactive about ensuring their compliance with billing rules.
Learning more about what billing practices might lead to white-collar criminal charges can help medical professionals and their support staff make better choices. Those implicated in allegedly fraudulent billing schemes may need help evaluating their situation and preparing an appropriate response, and that’s okay.