What happens when doctors commit health care fraud?

On Behalf of | Sep 10, 2021 | Health Care Fraud

When patients visit a doctor or stay in a hospital, they often hand over their insurance and billing information without much thought. The doctor and the health care facility’s staff should pay careful attention to all the billing steps to ensure everything is correct. However, “dirty doctors” in New York might enter false data to collect additional money from the insurance company or a patient. Such behavior is health care fraud.

Common ways to run health care schemes

Billing codes provide details about procedures. Medicare and health insurance companies go by the code when processing payments. An example of fraud is when a physician lists a much more extensive procedure’s code although a far less complicated procedure occurred. There are several ways a doctor might play with the codes to receive more money, and these actions may lead to a fraud investigation.

Health care fraud by “dirty doctors” might become noticeable when the Explanation of Benefits or the Medicare Summary Notice arrives. The reports could display the wrong procedure, revealing possible billing fraud. Not every patient reads these statements or checks them thoroughly. Therefore, a doctor could get away with health care fraud for many years with multiple patients.

Investigators may notice a pattern or receive a tip about the alleged fraud. The result might involve a doctor facing criminal charges.

Addressing fraud charges

Although something might appear to be fraudulent, a simple mistake may be why the wrong billing code went forward. Mistakes could happen on a series of bills if the error never receives a correction. Regardless, a doctor could still find him or herself in legal trouble.

When a prosecutor looks at a significant amount of evidence pointing to fraud, the doctor might have a hard time fighting the charges. A plea bargain deal may potentially lead to a better outcome than a jury trial.