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Medical billers could face charges for an employer’s fraud

On Behalf of | Jan 22, 2020 | White Collar Crime |

Working as a medical biller is a potential career with plenty of perks. Medical billing is a trained position that requires some education but not a college degree. As a result, those who are intelligent and organized may find this profession to be a lucrative option for a lifelong career that will always have demand.

Unfortunately, with the professional status and competitive pay involved in medical billing comes serious risk. Medical billers are often among the parties charged in cases of health care fraud. If the medical practice that employs you engages in fraudulent billing, you could wind up charged as part of that conspiracy, even if you never profited at all from the fraud itself.

Know the warning signs of billing fraud

The best way to protect yourself from getting caught up in something legally dangerous is to know the warning signs of medical provider billing fraud. The most common types of billing fraud include billing for services not rendered, billing for procedures more expensive than the one performed, intentionally unbundling discounted services to charge a higher amount, performing unnecessary procedures specifically to bill for them and “waiving” a patient’s co-pay or deductible.

Medical providers should only perform necessary procedures and tests. Incentives, including kickbacks for certain prescriptions or referrals, should not influence the care they provide. They should not bill for procedures they do not perform or intentionally charge an insurance company more money than they should pay on behalf of a patient. A doctor or practice manager asking you to change the records or bill for something other than what you see in a file is a major red flag.

Once you know these potential warning signs, it is easier to monitor the documents you process for indications of billing fraud. For example, if a patient that you know is bedridden comes in for an appointment but no one in the office saw them, that could be a reason to question the charges. If you know that the physician’s notes essentially instruct you to unbundle a combined charge, that could also be a red flag for fraud that could carry criminal charges in the future.

Not knowing about the fraud could be a valid defense

If you fail to notice red flags for fraudulent activity and no one explicitly informed you about questionable billing practices, you may wind up facing charges despite having no knowledge of what had happened or intent to commit criminal acts. Performing your job as a medical biller involves trusting the records provided by the physician.

Proving ignorance isn’t easy, but it is possible. It is one of many potential defense strategies that medical billing specialists have available if they wind up charged with a white-collar crime related to a potential medical billing fraud conspiracy.