In short, a medical billing scam is a criminal or civil fraudulent act that typically begins with an individual making a fraudulent communication to an individual that attempts to manipulate a targeted individual or system for their own financial benefit. Medical billing scams can take many different forms.
Some of the most common examples of medical billing scams include:
- Billing for Services Not Rendered: One of the most common medical billing scams, involves providers charging for services, supplies, or lab work that was never performed or provided to patients;
- Upcharging: Another common medical billing scam involves providers seeking reimbursement for more expensive services or supplies by inputting an incorrect billing code.
- For example, a provider may perform a simple routine checkup, but bill for a more costly specialized service or procedure;
- Fraudulent Telemarketing: Another common medical billing scam involves individuals reaching out to susceptible individuals, such as the elderly, and asking for payment for services that were not performed or bills that have already been paid;
- Unnecessary Procedures: A physician or medical provider that unnecessarily performs a procedure or bills for a different procedure other than the one they actually performed, may be charged with medical billing fraud.
- For example, a dentist that performs an unnecessary tooth extraction, or performs a simple filling, but then bills for a root canal, may be charged with medical billing fraud; and/or
- Fraudulent Medical Billing Reports: Physicians or providers are allowed to seek reimbursement for costs other than the direct treatment of a patient. This includes overhead expenses and other expenses attributable to Medicare or Medicaid patients.
- A physician or medical provider that knowingly submits false information in order to obtain a greater compensation than that to which they are entitled from the services they performed under their state’s Medicare or Medicaid program may be charged with fraud.
What Is Criminal Fraud?
Criminal fraud is a crime that involves a scheme to cheat or deceive another individual or entity in order to obtain some sort of financial gain. Criminal fraud is considered a white collar crime. According to criminal fraud law, any action that is intended to deceive another person or company through false representation of fact that results in legal detriment to the individual who relied on the information can be considered an act of criminal fraud.
Simply put, if an individual knowing lies about an important or key fact in a transaction or relationship and the other party relies on that misrepresentation of fact and suffers financial harm, criminal fraud has occurred. It is important to note that criminal fraud does not occur when an individual provides a fact they believe to be true, even if they are mistaken.
In the case of medical billing scams, if an individual lies or conceals a truth regarding a medical bill, and then another party relies on that false information and suffers financial harm, the individual that lied may be charged with criminal fraud.
What Is The Difference Between Criminal Fraud And Civil Fraud?
Although the exact laws may differ, the basic elements of fraud in both civil fraud cases and criminal fraud cases are essentially the same. However, a criminal fraud conviction can result in criminal fines and/or jail time. In addition, criminal law has a higher standard of proof (i.e. beyond a reasonable doubt). This means that each element of the crime must be proven beyond a reasonable doubt in order for a defendant to be convicted of criminal fraud
In criminal fraud cases, whether or not the fraud was actually successful is not a factor in determining guilt. The mere fact that an individual attempted and intended to commit criminal fraud is enough to charge someone for their medical billing scam. Depending on the jurisdiction and the facts of the case, criminal fraud may either be charged as a misdemeanor or a felony crime.
In civil fraud cases, the individual who was the victim of the fraud must prove all of the fraud elements discussed above, as well as proving that they suffered damages as a result of the fraud. The difference between a civil and criminal fraud case is that in a civil case, the individual must show actual quantifiable damages, whereas in a criminal case the prosecution only needs to show that the defendant attempted the fraud.
What Are the Penalties for Medical Billing Scams?
As noted above, medical billing scams may include both civil and criminal penalties. Most forms of medical billing scams and fraud are “wobblers.” In criminal law, the term “wobbler” refers to a criminal act that can be either punished as a felony or as a misdemeanor. The choice as to whether or not the accused defendant (i.e. the person accused of committing the medical billing scam) is charged as a felony or misdemeanor is typically made by the prosecutor at the time the defendant is charged with the offense.
Criminal punishments for medical billing fraud will be dependent on whether or not the individual is initially charged with a misdemeanor or felony. Potential felony punishments for criminal fraud could include imprisonment for a period of time between one year and five years, severe criminal fines of more than $10,000, or a combination of both. Additionally, an accused person may also be on the hook for double or triple the amount that they defrauded the individual or state Medicare/Medicaid program.
If the individual accused of the medical billing scam is charged with a misdemeanor, criminal punishments could include prison time of up to one year in a County jail, criminal fines of up to $10,000, or a combination of both.
It is important to note that an individual accused of a medical billing scam does have legal defenses that they can assert to have the charges brought against them reduced or dismissed. Although it may seem obvious, the main defense to a medical billing scam criminal charge is that the defendant did not act knowingly or with fraudulent intent.
For example, if a provider was simply mistaken and inputted an incorrect billing code, they may be forgiven and the charges brought against them could be dropped as they did not possess the criminal intent to be considered guilty of the crime.
What Should I Look Out For?
It is important to be on the lookout for any potential medical billing scams. For example, medical billing scams often appear on Internet ads, in the classified sections of newspapers, or in a targeted email communication. These ads may even appear next to legitimate ads for hospital medical claims processors.
One of the main indicators that the advertisement may be a medical billing scam is that the ad will promise a considerable refund or ask for payment to be made through a third party payment processor. Some ads may include a telephone number that an individual can call and speak to a fake agent. The fake agent will then try to get you to provide them personal information or billing information over the phone. It is always important to always first confirm any communication regarding medical bills directly with your medical provider.
Do I Need a Lawyer for Help With Medical Billing Scams?
If you believe that you have fallen victim to a medical billing scam, you should immediately contact an experienced consumer attorney.
An experienced attorney will be able to help you determine your best course of legal action regarding recovering for the financial harm you suffered. Additionally, an attorney will also be able to initiate a private civil lawsuit against the party that defrauded you. Finally, an attorney can also represent you in court, as necessary.
