When people see doctors in New York the health care provider typically bills their health insurance company for payment. Many people have private health insurance through their employer or pay for it on their own. Many other people have Medicare or Medicaid in place for their insurance. While people may see the medical bills and the portions that their health insurance company paid for certain services, they may not understand how medical billing between the healthcare provider and the insurance company works.
There are different codes for different types of services. Based on the billing code used by the health care provider, the insurance company will pay a certain portion of the bill. Therefore, the majority of the money that health care providers receive comes from how they bill the insurance company. Insurance companies rely on the codes used by the health care providers to determine the amount they pay.
The insurance company cannot always immediately verify if the provider in fact provided the service they say they performed though. There are different ways in which health care providers can commit health care fraud as a result.
Examples of Health Care Fraud
Some common examples of health care fraud are:
- Billing for services that are not medically necessary
- Billing for different services separately that should have been billed together as one code
- Changing medical records to justify false charges
- Charging for more expensive procedures when cheaper ones were actually performed
- Receiving kickbacks from different pharmaceutical companies or medical device companies
- Misrepresentation of charges in cost reports
People who are accused of doing one of the types of activities stated above could be charged criminally with health care fraud. These are serious allegations that have both professional and criminal ramifications and need to be taken seriously.
Many health care professionals are charged with health care fraud in New York. While the charges are serious, simply being charged does not mean that the medical professionals will actually be convicted. There may be defenses available to them and as long as they can avoid a conviction, they will not face the serious consequences that come with convictions. Experienced attorneys understand the potential defenses to health care fraud and may be able to help protect medical professionals’ rights.