What Constitutes Healthcare Fraud in Pennsylvania?August 1, 2017
With the recent crackdown on healthcare expenditures, the United States has taken a strong stance against healthcare fraud as a means of reducing false claims and, in turn, reducing healthcare costs. The Federal Bureau of Investigation has units in each of its main offices dedicated to detecting and investigating healthcare fraud, but what constitutes such fraud, and can you be convicted of a federal offense even if your intentions were to help a patient in need? The answer is yes, and you should contact a Pennsylvania criminal defense attorney immediately if faced with such charges.
Healthcare Fraud Defined
In a general context, “healthcare fraud” is classified as a “white collar” crime and includes filing false, unlawful, or dishonest claims with a health insurance company, including Medicare and Medicaid, as a means of turning a profit. However, healthcare fraud can also include taking “kickbacks” for patient referrals, waiving patient co-pays, and providing your health insurance company with false information about yourself or your claims. Charges for healthcare fraud are not limited to healthcare providers and can even be brought against patients themselves. Although some of the most common instances of healthcare fraud actually result from identity theft, it is important to recognize that even behaviors one might consider noble, such as waiving co-pays or changing billing codes so that a patient with limited insurance can have a necessary service covered, are considered healthcare fraud and subject the provider to liability.
Common Types of Healthcare Fraud
Some of the most common types of healthcare fraud include, but are not limited to, the following:
- Misrepresenting and billing a non-covered treatment as a covered treatment – for example, billing a nose job as a “deviated septum;”
- Falsifying diagnosis codes to justify additional surgeries, medications, and procedures;
- Waiving deductibles and co-pays and then overbilling the insurer to make-up the difference;
- Billing for services that were never rendered;
- Performing medically unnecessary services for the purpose of being able to bill for such, i.e., giving the patient a shot he or she does not need; and
- Billing for more advanced procedures than what were actually performed, i.e., billing for an expensive 3D ultrasound when the patient really had a traditional 2D ultrasound.
Unfortunately, healthcare fraud in the insurance billing process is common, especially when patients present with insurance plans, such as Medicare and Medicaid, which greatly discount what a physician is permitted to charge for his or her services. This is not an excuse for committing healthcare fraud, but it can become commonplace is an environment where financially troubled patients are in need of medical care they can’t afford and healthcare facilities are trying to make up for the deductions taken by certain insurance companies.
Contact Philadelphia Criminal Defense Attorney Brian Zeiger About your Healthcare Fraud Charges Today
It should come as no surprise that doctors and insurance companies often disagree on the level and necessity of care required by a particular patient, and what a healthcare company might deem “unnecessary billing” a doctor might deem medically necessary for the health and wellbeing of the patient. If you have been caught up in healthcare fraud charges, contact Pennsylvania white-collar defense attorney Brian Zeiger. He can work to review the specific facts of your case and help you defend against those charges. Call him today at 215-546-0340 or contact him online for a confidential, no-risk consultation.