According to the FBI, health care fraud leads to the loss of over $10,000,000,000 annually. That is over ten-billion dollars lost in the health care industry, leading to higher health insurance premiums and increased taxes.

However, the financial consequences are just the start. Health care fraud can lead patients to seek unnecessary medical procedures, and in some situations, this can have dire consequences.

The Complexities of Health Care Fraud

Fraudulent health care claims can be committed by anyone who is engaged in the health care industry, including physicians, medical office managers, and even patients in some circumstances.

Health care fraud includes:

Using false statements to obtain funding from health care programs.

Offering or receiving anything of value as a result of referring to a medicare or Medicaid business.

Making a claim or statement to the government that is knowingly false so they pay on a claim.

Making a referral for services to a family member or associate that will financially benefit the referring doctor.

The majority of health care fraud cases are built on false bills that are submitted to Medicare, Medicaid and Tricare. There are also reports submitted regularly from private insurance companies that can indicate potential fraud. However, there are some cases that originate from people who are aware of the fraud and decide to report it to law officials. These are considered whistleblowers, and they often include office staff, hospital workers, patients, and in some cases even former employees.

Regardless of how the fraud is reported, evidence is examined thoroughly before any charges are made.

Challenging Evidence and Presenting Counterarguments to Dispute Medical Fraud Allegations

When fraud allegations are made, the best thing that you can have on your side is documentation. Documentation that shows the intent of genuine medical care can reduce the threat of a charge of fraudulent activity.

Other evidence that can successfully challenge accusations of fraud include:

A thorough compliance plan that is intended to detect or defer fraudulent activity within your organization.

Evidence of consent between the physician and patient, or any other alleged victim.

The Importance of Early Intervention, Thorough Case Analysis, and Expert Testimony

Healthcare fraud can include a variety of different types of actions, including the falsification of certificates of necessity which makes it possible to bill insurance companies for procedures neither necessary nor intended to be carried out, as well as the upcoding and up-bundling of medically necessary medications and procedures so to make them more expensive for the insurance company or patient.

If you believe that there is a potential claim of medical fraud that can be made against your practice, seeking support to clarify the situation is the best step to take, as early on as possible.

Providing your legal team with access to all existing documentation that connects to the potential fraudulent activity will allow them to thoroughly analyze the line of thought that was behind the accused action. Fraudulent activity places a lot of emphasis on intent. If the document shows genuine intent, then the fraudulent charges won’t stick. 

Preventing Fraud Allegations to Ensure Compliance with Healthcare Regulations

If the physician or healthcare employee acted in good faith when delivering the medical care, but made some sort of mistake, such as accidentally committing information, making an error, or billing improperly, then they cannot be convicted of health care fraud.

It is the job of the defense team to find evidence that clears accusations of fraud by demonstrating without a doubt that the intent of the physician or medical care facility was genuine.

To prevent medical fraud, stay up to date on regulations, document all interactions with patients, and make a practice of having patients sign consent forms to indicate that they acknowledge your medical knowledge and take your suggestions of referrals to particular practices as an indication of respect and support. Taking preventative actions can show that you acted to your best ability to prevent fraud, and in many cases that evidence will be used to justify good faith.