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Posted on January 15, 2016 in Crime

Medicare Fraud: Federal Charges Physicians May Face for Billing Too High

A physician can face federal charges and fines or incarceration for improper Medicare billing. If a doctors knows, or should have reasonably known, the billing information was unreasonably high, then the act of billing is considered fraudulent. Here’s what you need to know to protect your practice:

Medicare Compensation Is Not Free Money

Many physicians slip into unethical practices when they believe there is no victim if they over bill Medicare insurance. Health care practitioners who engage in fraudulent billing practices, at any level, are stealing money and health care affordability away from taxpayers and people who have earned the right to use Medicare.

Laws That Govern Medicare Billing and Federal Fraud

When you fail to accurately bill for Medicare services, you may face scrutiny under several government agencies including the Department of Justice, the Department of Health & Human Services, and the Centers for Medicare and Medicaid Services.

In addition to laws that prevent doctors from accepting or offering kick-backs, numerous federal laws prevent healthcare practitioners from knowingly billing an unreasonably high rate with the intent to defraud the program. If the government discovers evidence of extensive billing errors, a physician could face penalties under several independent statutes.

What Are the Chances That Regulators Will Catch Exaggerated Billing?

In mid-2015, the Department of Health and Human Services conducted a country-wide Medicare Fraud sweep and filed charges against 243 healthcare practitioners. Among the professionals included in the charges were 46 licensed health care professionals. The strike force discovered $712 million worth of false billing evidence.

Getting away with fraud was easier before computerization. Today, most billing is entirely electronic, and improved record-keeping practices have made fraud detection easier than ever. Since the Affordable Care Act was passed, key oversight agencies have started using more technology to identify and catch fraudulent and potentially fraudulent activities in the healthcare industry.

If your billing documents do not match certain predefined terms, you may face a government investigation. Even physicians who pay close attention to their billing practices may need to defend their billing on occasion. Health care practitioners should prepare to defend all billing practices in the event of an audit, inquiry, or investigation.

Billing for Services Accurately

When you file a bill with Medicare, you are billing the Federal Government. Engaging in any of the following activities is considered a billing violation that may be subject to criminal and civil charges:

  • Billing for services that were never provided
  • Billing for unnecessary medical tests or treatments
  • Billing for services provided by someone who is not included in federal program coverage
  • Billing for services provided by employees who were not properly qualified or supervised
  • Redundant billing (billing for services that were already covered in a separate billing matter)

To prevent false or exaggerated billing, physicians should thoroughly document medical treatments and procedures for each Medicare patient. Include information regarding your reason for providing certain treatments, the time, and the circumstances. The better records you keep, the easier it will be to prove your billing amounts were not inflated.

As of 2014, physicians are also subject to an OPEN payments program, which creates transparency between physicians and industry service/equipment providers. All physicians should understand the reporting requirements of the program and routinely review information submitted regarding individual practices.

Facing False Charges

Increased oversight catches more criminals, but it also puts honest health care professionals in the crosshairs. If you have been accused of improper Medicare billing and face a false or exaggerated Medicare fraud investigation or charges, you will need an experienced attorney. Federal health care fraud charges are serious, and one investigation can damage your reputation. Don’t risk your reputation, contact the criminal defense attorneys at Orent Law Offices today for concerns about billing or fighting a claim.