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What is considered health care fraud?

On Behalf of | Jun 30, 2022 | Health Care Fraud

Anyone who visits a health care provider likely wishes the professional to behave honestly. However, some providers skirt ethical rules and the law. A doctor could order an unnecessary blood test from a Texas lab for no reason other than to raise a bill. Such actions may leave the physician facing legal troubles.

Health care fraud remains a problem

Health care fraud drains law enforcement resources and drives up the costs of medical care. Such fraud continues to be pervasive because it takes numerous forms and can go undetected for some time. The National Health Care Anti-Fraud Association suggests that the sheer volume of fraud-related financial losses reaches tens of billions of dollars annually.

Some attempts at health care fraud involve little effort, making the schemes more prolific. Billing the insurance company for care not performed might defraud insurance providers for years. A patient may not look at the statement of benefits or billing documents and never know such false billing occurs.

A patient might not know a doctor opted for a more expensive treatment plan solely to make more money. Some patients may undergo procedures they don’t need, but the health care provider recommends the procedure for the payoff. Again, significant time could pass before anyone realizes that fraudulent activities are occurring.

Investigations and health care fraud

Once insurance providers, patients or law enforcement officials suspect health care fraud, expect an investigation to follow. In some cases, the investigation might lead to a grand jury indictment. However, as with other white-collar crimes, an indictment doesn’t necessarily mean the accused will face an unavoidable conviction.

Sometimes, accusations about false billing derive from honest mistakes and not deliberate attempts to deceive and defraud. A physician could counter claims that an unnecessary procedure was necessary based on evidence. So, persons accused of fraud may have a valid defense.