What Do You Consider A Medical Billing Fraud?

Medical billing fraud makes all of us increase healthcare costs. It is an attempt to receive payment fraudulently from an insurance provider. Medicare and Medicaid, due to their payment arrangements, are particularly sensitive to fraud.

With all the talk of health care reform by policymakers these days, that waste to reduce costs is receiving a lot of coverage. Looking at what is spent on Medicare and Medicaid, not to mention private insurance, there are plenty of billing fraud opportunities.


A patient visits the hospital to seek treatment for the sprained ankle, but the insurance provider is charged with a fractured ankle by the doctor. How do you do that?

This fraudulent practice was coined as ‘upcoding’ because your doctor or healthcare provider must attach a CPT code to each procedure performed – and that code dictates how big or small the bill will be. Since its often big insurance firms routinely handle thousands of computerized statements, many poorly coded procedures can easily be missed.

Ghost Billing

One of the most common types of fraud involves billing services that were not carried out. This type of fraud affects the costs of health care since it only increases costs by the fact that the charges are not justified, but millions of dollars are spent each year tracking and finding and preventing this fraud. The government has formed RACs (Revenue Audit Contractors), which are paying a percentage of fraudulent or illegal billing practices in the last three years.

This form of fraud not only has a substantial financial effect on the government but also affects a patient’s health insurance. False reports for operations that have never taken place remain on the patient’s medical record and therefore, may impact the insurance or the care of potential physicians.

Unbundling Service

Unbundling happens when a kit contract involves several procedures to be paid separately, thereby generating a higher invoice.

Unbundling is another type of upcoding called “fragmentation,” which usually affects patients who have Medicare and Medicaid, as they generally have different reimbursement levels for specific categories of frequently performed procedures like blood test panels to be sent to the laboratory. Healthcare providers who seek to raise income fraudulently will drop the special package prices and separately charge each part of the test.

Self Referral

Self-referral happens when a physician requests examinations for a patient refers to himself or a member of the staff by whom financial compensation is received in return for the review. For instance, a surgeon who suggests and promotes an operation that he or she conducts is illegal. This is to prevent the promotion of unnecessary procedures and the overuse of services in the law prohibiting self-referral.

Benefits in Hiring a Lawyer for Medical BillingFraud

You may be able to hold an individual or a health care provider responsible and compensate for medical expenses and other damages by filing a complaint.

  • A promoter of medical fraud has proven expertise and outcomes.

A specialist in medical fraud works mainly on cases of fraud. We are not just retired attorneys who are familiar with criminal law.

You should hire an attorney for medical fraud as he has a strong background in complex reimbursement regulations for Medicare and Medicaid, including Stark’s and Anti-Kickback Statutes.

  • A prosecutor in the field of medical fraud knows the local court system.

A Medical Fraud Attorney’s knowledge of the local court system is one of the most significant advantages.

A Medical Fraud lawyer is familiar with the right people – the judge, prosecutors, the clerk ‘s court, and everybody involved in the law. His local relationships form a pattern of persuasion between judges and provide a strong reputation in his legal profession.

Due to his great accessibility and convenience in giving legal consultation, a medical fraud lawyer is favorable to a non-local person.

  • Your side is safe with a medical fraud lawyer.

Regardless of whether you have experienced physical, financial, or even emotional damage, a medical fraud lawyer will never give up and will work for you in a dispute.

A medical fraud lawyer tracks your history, previous experience, and related activities in the case. As he wants to win the case, he wants to develop a professional relationship with you.

Therefore, you are joined by a medical fraud lawyer at all stages of legal proceedings. He never gives up until a judge is convinced.

  • A counsel for medical fraud operates with caution and discretion.

A medical fraud attorney knows how to prevent dismissal and lose cases by ensuring the papers are correctly filed and pleadings and motions submitted on time before their deadlines.

You always retain their discretion by exercising privacy and are entirely responsible for maintaining your data and your case information.

As the Healthcare Fraud Group announced today, the majority of fraud cases are focused on falsified bills sent to Medicare, Medicaid, and TRICARE, although such crimes can also include falsified invoices sent to private insurance companies. The following are the most common fields of health fraud that you should learn about.

Schemes for Kickbacks

Kickbacks are rampant in the healthcare industry. In general, something of interest (e.g., cash, equity or gifts) is illegal for any doctor or medical facility from another doctor, a healthcare provider, a pharmaceutical company, or any other medical device manufacturing business to refer to patients at an individual pace, meet an absolute requirement, prescribe a specific medicinal product or make a decision that may lead to a particular medical device.

Medically Unnecessary Services

Medicaid and Medicare can only reimburse for medically necessary procedures or expenses. If you assume that your doctor recommends tests, treatments, scans or some other medical intervention that is not or appears not applicable to your condition, a referral could be medically unnecessary, in breach of the federal medical laws.

Failure to Adequately Bill Prescription 

This violates system rules and can also lead to an affirmative lawsuit against the pharmacy under the False Claims Act. Under regulations, a pharmacy will charge equal market value to Medicare and Medicaid patients for the medications that are the same price paid to all clients.

Wrong Procedures and Examinations

In compliance with the Medicare and Medicaid billing laws, only a physician can perform those procedures. Nevertheless, a growing trend is for nurses or office staff to perform regular outpatient procedures while paying the hospital for the doctor’s time. 

This is not only unethical, and a false assertion, but may also pose severe risks for the patient if an incompetent or undertrained staff member conducts a complicated medical procedure. If you encounter this in your doctor’s office, we urge you to speak to The Malpractice Group lawyers. The debate is open and confidential.


Probably the most common way of defrauding the government is the billing of services that were either never delivered or billed for one service, where there were similar but cheaper. When you see unexpected charges, not in line with your actual appointment, this kind of fraudulent screening activity can be extended to your doctor.

Healthcare Frauds and Fines

In the federal trial, there are several different forms of fraud in health care. Any of them are most widely used by federal prosecutors whenever they sue an individual with a federal court crime. Here are some of them including different healthcare fraud defense ways.

  • Health Care Fraud (18 U.S.C. § 1347) – This code provision is the federal law of essential health care fraud. The legislation forbids the making of a false statement or attempts to defraud the system in healthcare. This legislation covers fraud affecting public health and private insurance schemes funded by the government. The punishment for fraud of this sort is up to 10 years in jail, although the federal penalties will impose a much lower sentence based on the amount of money involved.
  • Health Care Fraud Conspiracy (18 U.S.C. § 1349) – This provision of the Code includes conspiracies involving fraud in medical care. The legislation forbids two or more individuals from consenting to a scheme or attempt to commit any form of fraud in healthcare. The project will not proceed for anyone to be accused of this crime. Everything the government needs to show has decided to do something that breaches the fraud law on healthcare. Although many different conspiracy laws can apply in a fraud case, this is the most commonly used by prosecutors. An individual convicted of fraud in healthcare faces a prison sentence of up to 10 years.
  • Wire and Mail Fraud (18 U.S.C. § § 1341 and 1343) — Any fraud, not only health care fraud, where a person uses mail or any wire communication to cheat an individual out of money, is covered by this Code Section. Those sections may contain the same kind of conduct as those protected by the law on significant health fraud; prosecutors tend to use these offenses to intimidate a criminal with a longer sentence. In most cases, a person convicted of wire or mail is in jail for up to 20 years.
  • False Claims Law (18 U.S.C. § 287) – It is unlawful to make a falsified petition to the government for reimbursement (such as a medical service or equipment invoice). In most cases referred to under the False Claims Act, a health care provider submits bills for medical services or supplies not given or not medically required for a patient. The punishment for violating this law is a jail term of up to five years.

Author Credits For Contributor James S. Bell P.C

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With over fifteen years of experience, James S. Bell P.C. has forged a name as a leading United States trial attorney. Most notably, Bell obtained the largest verdict in the United States in 2017 and the ninth (9th) largest verdict in United States history against JPMorgan Chase Bank for in excess of $6,000,000,000 (6 Billion Dollars).

Bell has become a recognized legal thought leader through projects such as co-authoring an article titled “Piercing the Corporate Veil” regarding property division in divorce and features in publications such as Forbes, Inc., and Entrepreneur and has been granted recognitions such as Best Personal Injury Attorney and Litigator of the Week.

Bell is in admission with the Bar in the States of Texas, California, and New York, and obtained his undergraduate and law degrees from Southern Methodist University. He continues to serve in a wide breadth of cases, including but not limited to healthcare disputes; Qui Tam litigation; white-collar criminal defense; catastrophic injury; ERISA; business fraud; bankruptcy; professional negligence/malpractice; oil & gas; complex securities disputes; divorce; child custody; and real estate fraud cases.

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