April 30, 2020

‘Upcoding’ and other forms of health care fraud

If you are a patient or medical professional accused of committing criminal health care fraud, you could face prison time or be subject to weighty fines if convicted. In addition to that, there could be further collateral damage to your career, reputation, and professional standing.

Insurance companies are eager to minimize their payouts to patients and medical providers and to recoup their profit losses from medical bills, and so the insurers are always on the hunt to make claims of health care fraud. Trillions of dollars are spent in the health care industry each year, and fraud does occur on occasion, but that doesn’t mean you’re guilty of the allegations. 

What health care fraud may look like

Health care fraud can take a variety of forms and be committed by both patients and medical personnel. Some common accusations of health care fraud include allegations that the insurance company was billed for unnecessary procedures or for medical services that were never provided. However, the insurance company wasn’t there to see the operation, nor do they know better than a doctor what a patient needed. You were there, and you should have records to back up your case that the services were necessary and were performed.

Another method of fraud is called “upcoding.” It involves inaccurately billing for a more expensive and higher-level version of a medical service rather than charging for the simpler, cheaper service that was supposedly actually performed. For example, a doctor might be accused of upcoding if an insurance company alleges they were billed for a 45-minute examination of the patient but the patient supposedly only got five minutes to talk to a nurse. Or in another example, it could be thought to be upcoding if the hospital billed for treating a patient of pneumonia, but the patient apparently only had a mild case of the common cold.

Getting legal defense

If you are facing charges of health care fraud, it’s vital that you safeguard your legal rights and have a skilled defense attorney fighting on your side to see you get the fairest treatment available under the law. Don’t let a crime you didn’t commit ruin your future.

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