As the United States moves toward a health care system that is profit-seeking and funded by private insurance companies, it is natural for clinics, hospitals, and doctors to want to make a profit too. In their zeal to make a profit, however, health care providers may step outside the bounds of honesty and commit fraud, even against public programs such as Medicare and Medicaid.
Health care fraud occurs when medical providers lie to insurance companies about medical procedures performed, in order to receive insurance payouts.
Health care fraud is specifically addressed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which made it a federal criminal offense carrying a prison sentence of up to 10 years. Violators of this prohibition against healthcare fraud often end up in a minimum security federal prison for white collar offenses. Most significantly, perhaps, substantial fines can be imposed.
Forms of health care fraud are as broad as the imagination. The most common form is billing for procedures never performed or for more expensive procedures than were performed, known as “upcoding”. Homeless people and low-income workers have been invited to get free shots or simply sign a sheet for $25, and then the medical provider claims services that never occurred. "Unbundling", where each step of a health care procedure is billed as if it were a separate and more expensive procedure, is also very common.
Another health care fraud scheme is misdiagnosing a falsely severe diagnosis in order to justify the treatment, and then performing unnecessary and dangerous procedures. Medical providers can also accept kickbacks for patient referrals. Another scheme is stealing identities in order to submit totally false claims.
These health care fraud schemes can be very lucrative. However, there are two sides of the story, and health care fraud can be committed by the insurance companies in their never-ending goal of avoiding and delaying payouts. For example, an insurance agent may tell patients that it fully investigated the medical incident, when in fact it may have only partially done so. More often, however, insurance companies are liable for violating their implied promise of “good faith and fair dealing.”
Healthcare fraud schemes can be very complex and may not be readily apparent. If you think that you have been the victim of healthcare fraud, an attorney can help you figure out how to best pursue a remedy for the harm you suffered. Alternatively, if you believe that you have been wrongly accused of committing healthcare fraud, a lawyer can represent you in court and help you to defend yourself against false accusations.
Last Modified: 05-21-2014 03:54 PM PDTLaw Library Disclaimer
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