A New York Defense Lawyer Explains Coding Fraud Crimes
Billing Medicare and other insurance companies is very complicated for providers. Insurance codes have been developed for every service provided to patients, and providers must ensure they use the correct codes for the services being performed. Unfortunately, this can lead to mistakes being made.
In some cases, improper coding can actually be considered illegal medical billing fraud. Individuals, medical practices, and hospitals or other large care providers can all be accused of medical coding fraud and can all face the threat of serious legal consequences. If you find yourself or your business accused of wrongdoing, contact Bukh Law Firm, PLLC for assistance. Our New York legal defense team has experience with medical billing fraud cases and we can represent and advocate for you as you face criminal and civil actions.
What is Medical Coding Fraud?
When prosecutors bring claims against defendants for medical coding fraud, the prosecutor has the legal burden of proving the case. A simple mistake in coding and billing insurers should not lead to criminal conviction. However, if intentional false claims are being made to Medicare, Medicaid, Tricare, other government insurers or other private health providers, criminal prosecution can be initiated. Some of the different types of fraudulent medical billing which can prompt state or federal charges to be filed include:
- Upcoding: Insurance companies are billed for a medical procedure which is more complicated and more costly than the procedure that the patient actually received.
- Unbundling: This occurs when there is a code for bundled services, but the provider or billing service “unbundles” the service or breaks the testing/treatment down into different parts. Each individual part of the test/treatment is billed for separately, generating a larger payment from the insurance provider .
- Coding for unconfirmed diagnoses. Medical information is provided to insurers regarding patient diagnoses, which are used to justify the treatment a patient is receiving. Codes may be included for conditions a patient does not have, so the providers can charge for medically unnecessary services or for services that should not be covered.
- Inflated charges: Patients are charged for more services than they need or for services that are not actually performed.
Medical coding fraud does not necessarily need to result in an insurer actually making improper payments. A defendant can be charged with criminal wrongdoing for purposefully submitting false claims for benefits or payments, even if the medical coding fraud is not successful and the insurance provider does not actually make the requested payments.
What are the Penalties for Medical Billing Fraud and Abuse?
Penalties for medical billing fraud and abuse are very serious. Health care fraud and health insurance fraud frequently trigger federal charges, including charges under 42 U.S. Code Section 1320-a-7b that could carry the potential for as long as five years imprisonment. Defendants may face multi-count criminal charges if they were involved in fraud schemes for a long time or if they engaged in multiple fraudulent billing transactions.
Criminal charges brought by the federal government or by the state are only the start of consequences defendants frequently face when accused of medical billing fraud and abuse. Fraudulent medical billing could also result in Qui Tam lawsuits being filed under the Federal False Claims Act, or in civil lawsuits being filed by federal authorities. Qui tam lawsuits are civil suits brought by whistleblowers accusing defendants of fraud against the government. Plaintiffs who bring such suits are rewarded for their role in helping to recover taxpayer funds by getting to keep a part of the money that is obtained from the defendant if the defendant loses the case.
How a Defense Attorney helps with Medical Billing Fraud Cases
Bukh Law Firm, PLLC has represented clients in many medical billing fraud cases. We understand the complexities of laws and regulations applicable to billing insurance companies and we work hard to investigate allegations against you and develop a strategic defense strategy. The goal is to help you keep your money and stay out of jail, or to minimize any penalties and consequences associated with criminal and civil liability. To learn more and to get started today on building a defense with the help of an experienced NY fraud lawyer, give us a call.
