The healthcare industry is one of the most highly regulated industries. Fraud in the healthcare industry ends up costing taxpayers billions of dollars every year. That means both federal and state governments are eager to crack down and eliminate medical fraud at every turn. Organizations even accused of committing healthcare fraud are put through a variety of investigations and tests. Facing these alone without a healthcare fraud lawyer can worsen an already stressful situation.
What NOT to Do During a Healthcare Fraud Investigation
What is Healthcare Fraud?
The Center for Medicare and Medicaid Services (CMS) defines fraud in healthcare or Medicare as “deliberate and dishonest acts committed to benefit the person committing the act or someone not entitled to the benefit.” Health care fraud occurs when a business or someone knowingly and willfully uses a healthcare benefit program dishonestly.
Here are some of the most common examples:
- Misrepresentation of the level or type of services provided.
- Misrepresentation of the individual rendering service.
- Billing for items and services that have not been rendered.
- Billing for items and services that have not been adequately documented.
- Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service, often known as unbundling.
- Seeking increased payment or reimbursement for services that are correctly billed at a lower rate, known as upcoding.
- Misusing codes on a claim.
- Charging excessively for services or supplies.
- Billing for services that were not medically necessary.
Most healthcare professionals would never commit an act of fraud on purpose. Committing fraud by accident can still land these professionals in hot water.
For an act to be legally considered as fraud, the person involved must knowingly engage in fraudulent activities. That means a simple mistake doesn’t necessarily mean the action is fraud. A typo that results in a patient being billed for additional treatment isn’t necessarily fraud unless the person makes the error on purpose.
Of course, despite claiming that fraudulent activity was done in error, an investigation may still be carried out. Further, even if you’re unaware that someone in your office is committing fraud, it does not necessarily mean that you will not ultimately be implicated.
Mistakes You Should Avoid During a Healthcare Investigation
If the government decides to investigate you or your office for healthcare fraud, you want to respond appropriately in order to protect yourself. The first step is to hire a healthcare fraud attorney. This will ensure that you have a guide who understands the process and aggressively work to protect your interests.
Here are the most significant three mistakes people make when facing an investigation:
Ignoring the Investigation
Whether there is evidence fraud took place or not, the investigators will approach the process as if you are guilty. Ignoring the investigation will only hurt your case.
You might think that ignoring the investigation will make it go away. Sadly, all this does it make the investigation happen without your input. Those in charge will gather evidence, write reports, and make a recommendation.
If you ignore their work, you won’t have a chance to tell your side of the story. By the time someone actually contacts you, they most likely have already built a case. This only strengthens the need to have an experienced attorney on your side.
Keep in mind that a recommendation regarding the existence of medical fraud could result in criminal charges, civil lawsuits, loss of professional licenses, and more. This isn’t an area you want to take lightly.
Not Having a Healthcare Fraud Attorney on Your Team
No matter how nice they may seem, investigators are not working in your favor. They aren’t there to help you; they are there in hopes of catching illegal activities.
Just like with the police, anything you say can go into their report. Even trying to explain an innocent situation could be used against you.
Working with an experienced health care fraud lawyer will make a huge difference. Your attorney can work with the investigators directly to understand their concerns and what evidence they may have gathered.
If you meet with the investigation team, your attorney can help ensure that your rights are protected during the entire process.
Not Preparing Your Side
The investigation stage is the best time to resolve a suspicion of medical fraud. In many cases, your lawyer can help you make sure that this happens. Healthcare fraud investigators aren’t simply going to take your word. If you take the time to prepare your side of the case, you can potentially defeat the accusation against you.
This is another area where a seasoned healthcare fraud attorney will help. He or she will look at what the investigators have in their evidence files and help come up with a strong defense from there.
How to Protect Yourself
According to the FBI’s work on healthcare fraud, there are several things that patients and medical practitioners can do to prevent instances of fraud. While you should have trust in your providers, patience, and supporting staff, you should also be cautious.
For Patients
- Keep your insurance cards and benefit information safe. Only give insurance information when it’s necessary.
- Don’t accept unnecessary equipment or products. Make sure you understand why any equipment, devices, or medication is being prescribed.
- Double-check medical supplies. You should only get what was ordered; nothing more or nothing less.
For Medical Practices
- Document everything. Make sure you note why you are prescribing medications, medical equipment, etc.
- Invest in training. Since simple mistakes can result in the appearance of fraud, make sure people working with billing codes are well trained.
- Conduct regular audits to identify and correct errors.
- Have a clear policy regarding all things fraud-related.
Help is Available
Medical fraud is a serious charge. While mistakes will undoubtedly happen, you don’t want to be caught in an investigation that could have negative consequences. By taking simple steps on safeguarding your information and practices, you can protect yourself from unnecessary investigations.
If you are suspected of healthcare fraud, don’t waste time trying to deal with it on your own and hire the appropriate healthcare fraud attorney. You’ll be thankful that you did.
