Healthcare providers working with federal benefit programs require a proactive approach to compliance. However, due to opaque regulations and increasingly complex compliance requirements, many growing healthcare companies and specialists within the medical field now face billing fraud charges. Billing fraud charges impact all aspects of a professional’s business and personal life, with many facing millions of dollars in fines, the loss of their practice license, and even jail time in cases of significant billing fraud.
Fighting back against billing fraud charges begins with understanding the terminology and learning the full extent of your legal rights.
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Billing Fraud Charges
Understanding the reasoning behind billing fraud charges ties into learning about the specific charges covered by medical billing regulations. The most common billing fraud charges include:
Upcoding
Upcoding is a type of fraud relating to a provider sending a bill to Medicare or another payor for a more expensive service than they performed. Examples of upcoding violations include:
- Overly state the use of equipment in a procedure
- Overly state the time taken to perform a procedure
- Falsely stating the number of staff performing the procedure
- Making up a procedure that didn’t occur
Unbundling
Unbundling is a crime under healthcare fraud laws in which investigators accuse providers of separating various medical procedures into unique codes to increase reimbursements. The process of unbundling is also known as fragmentation.
Examples of unbundling in medical fraud cases may include:
- A blood test company separates the billing for each test within a blood test panel for one patient
- Nursing facilities are allowing outside suppliers to bill patients separately for their services
Billing for Services Not Provided
It’s a violation under the False Claims Act’s billing regulations to bill the government agency for services or equipment not provided. Many providers facing billing fraud charges for services not provided may have simply charged for a different service. This occurs when an employee inputs the wrong code. In such circumstances, your billing fraud lawyer can investigate the claim and determine that the fraud was a mistake, helping show investigators you did not intentionally bill for a service you did not provide.
What is the Scope of Billing Fraud Laws?
Billing fraud is a widely used term that encompasses a range of healthcare industry violations relating to reimbursement requests to federal benefit programs such as Medicare.
The False Claims Act (31 U.S.C. § § 3729-3733) is the law under which healthcare providers face billing fraud charges. Passed in 1863, the FCA intended to target fraud in government contracting and against government authorities. However, the scope of the False Claims Act has widened in recent years, with the Department of Justice reaching record recoveries and increasing its aggressive pursuit of medical professionals.
Criminal penalties for violations of the False Claims Act include imprisonment and fines. The Office of the Inspector General may also impose additional civil penalties for false or fraudulent claims.
If you’re facing an investigation for billing fraud, you may also face charges under the Stark Law. The Stark Law relates to physicians billing for “self-referrals” or the Anti-Kickback Statute, a criminal law prohibiting the knowing and lawful remuneration to reward patient referrals. Under the Federal Health Programs, paying for referrals is a crime subject to severe penalties. For example, physicians who pay or accept kickbacks can face fines of up to $50,000 per infraction.
The Steps To Take When Charged with Billing Fraud
If you or your healthcare business are under investigation for billing fraud or facing billing fraud charges, there are clear steps you should take immediately.
Speak with an Experienced Billing Fraud Defense Lawyer
Your first call should be to a healthcare fraud defense lawyer with experience in billing fraud cases. Review the company’s track record in handling cases and take the time to note your questions before the free consultation. During the consultation, discuss your knowledge of the charges and ask about the steps you can take in the coming days to protect yourself and your healthcare business as investigators comb through your records. Your lawyer can also help you begin collecting evidence in your defense. Bringing a skilled fraud defense firm as soon as possible gives them more time to analyze your case and protect you against civil or criminal liability.
Begin Collecting Billing Details
Coordinating with your lawyer, begin collecting all documentation related to your billing practices. Collect invoices, emails, and checks. Provide your legal team with as much information as possible about your billing process. They can then help you organize the evidence and use their legal experience to show you did not break any laws.
Communicate Only with Your Lawyer
Your lawyer will also explain how to protect your rights when communicating with other stakeholders, including employees, colleagues, and patients. Speak only with your lawyer regarding your case, and address all questions from investigators and other parties to your legal defense team.
Billing Fraud Defense Q&A
Which Agencies Investigate and Prosecute Billing Fraud cases?
If you or your healthcare team are facing a billing fraud investigation, the following government agencies may be involved in your investigation and prosecution:
- Department of Justice (DOJ)
- Federal Bureau of Investigation (FBI)
- Centers for Medicare and Medicaid Services (CMS)
- Department of Health and Human Services (HHS)
- Department of Labor (DOL)
- Drug Enforcement Administration (DEA)
- Office of Inspector General (OIG)
How Does the Federal Government Identify Billing Fraud Investigation Targets?
The government uses data analysis to determine when billing anomalies occur and then launches an investigation. There are also “Qui Tam” investigations, in which a whistleblower reports to the federal authorities, and the OIG and DOJ substantiate their claims.
What Are the Possible Defenses for Billing Fraud Cases?
While the False Claims Act is comprehensive and broad in its focus, the federal government recognizes that healthcare providers have legitimate defenses to billing fraud claims. Potential defenses to discuss with your lawyer may include a lack of knowledge of the fraudulent activity or that the charge stems from an unintentional error by a team member. You can also show the investigators detailed and accurate documentation and prove you completed regular billing process audits.
Turn to Lowther | Walker’s Healthcare Fraud Defense Lawyers
With a background including landmark victories in billing fraud defense cases, Lowther | Walker is ready to protect you and your team against investigators. Contact our offices at 404-806-7997 to book your free confidential consultation, and our legal team will immediately begin work building a robust defense of your charges.