Man with stethoscope holds his hands in handcuffs before itself with money in his pocketIt costs taxpayers billions of dollars each year. Medical billing experts claim that the United States government loses 30 cents out of every dollar earned from medical billing fraud.[1] Medical Billing Fraud, also known as healthcare fraud, is a serious issue that affects American healthcare cost, taxes, and even the health of patients.


What is Medical Billing Fraud?

Medical billing fraud can cause serious health harms to its victims. Individuals who are exploited may be subjected to unnecessary and even harmful, sometimes life-threatening medical procedures. One cardiologist who was sentenced to twelve years in prison for medical fraud had performed 750 medically unnecessary heart procedures. At least two patients died, and it was later discovered that the doctors and hospital staff had persuaded indigent people to fake symptoms and receive the unnecessary procedures, in exchange for food and cigarettes. See id. Clearly, medical billing fraud is a serious issue with legal implications. It is so serious that it is even on the government’s radar, where a Medicare Fraud Strike Force exists to catch and prosecute medical billing fraud. Just recently, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced that they had taken down fraudulent operations in six cities, resulting in 90 charges for $260 million in false billing. HHS Press Office, “Medicare Fraud Strike Force charges 90 individuals for approximately $260 million in false billing,” May 13, 2014.

Clearly, medical billing fraud is an important issue in our nation’s medical and legal landscape. The question is how can it be identified, and what can expert witnesses do about it?

There are several types of healthcare fraud, but the most commonly identified consist of the following:

(1). Phantom Billing: Billing for a service that was never provided.

(2). Upcoding: A service was provided, but instead of billing for that service, a patient was billed for a more expensive service. For example, a patient with a cold might be billed as having pneumonia.

(3). Providing unnecessary services, simply to add to the bill and not because a patient needed them.

(4). Unbundling: Many services are billed together at one amount, but providers who “unbundle” will instead bill each of those services individually at a higher amount.

(5). Balance Billing: Billing patients for more than their copays.

(6). Referrals/Kickbacks: Accepting referral fees from other providers or making self-referrals.

Congress has deemed all of these acts illegal and criminally punishable in the 1996 Health Insurance Portability and Accountability Act (HIPAA).

The Legal Aspects of Medical Billing Fraud

Healthcare fraud is a federal criminal offense by statute. See 18 U.S.C. §1347. Nearly all cases of this type are prosecuted in federal court, largely because almost every dollar spent on healthcare can be traced back to Medicare, Medicaid, or insurance offered by corporations that operate in interstate commerce.

Medical billing fraud cases are complicated and require large numbers of expert witnesses, particularly medical coding experts, nurses, physicians, and computer experts. Often, these cases involve enormous amounts of computer-generated evidence, and attorneys need experts, both to retrieve such information and to interpret and explain it as evidence. Because healthcare fraud is a criminal matter and nearly always a federal matter, attorneys on both sides must be well-versed in every aspect of prosecuting or defending a federal criminal case. Experts are invaluable in helping navigate this process, particularly those who understand the healthcare system.

Expert witnesses are able to provide solid opinions pertaining to Medicare and Medicaid fraud, medical billing processes in general, and medical records. Consulting experts can help by creating reports that pertain to medical billing claims, explanations of benefits (EOB), and coinsurance payments (copays). Medical insurance experts are needed to testify about deductibles, copays, and out-of-pocket medical expenses. In addition, independent physicians can review medical charts and point out inconsistencies or patterns in the treatment different patients received. Attorneys may also find themselves in need of experts who are independent medical examiners to provide objective perspectives on a particular case. Medicare and Medicaid specialists are indispensable in cases involving fraud committed with respect to either government-funded insurance system. In cases involving upcoding or unbundling, experts in medical coding can help crack a difficult case by explaining what procedures were billed for versus what might have been medically necessary. Medical billing experts can help to decipher a clinic’s documentation and determine if that documentation is adequate or consistent. Healthcare experts consist of medical reimbursement specialists, accountants, fraud examiners, medical investigators, credentialed coding experts, medical record examiners, and health information specialists, as well as nurses and doctors.

Conclusion

Whether an attorney is prosecuting or defending in a case involving medical billing fraud, significant investigation, document review, and analysis of the materials involved in a given case are all needed, and this is where the experts play a key role. Given how costly healthcare fraud is, in terms of money and health, it behooves attorneys in this field to stay on top of their game by availing themselves of medical billing experts early and often.

By: Kat S. Hatziavramidis, Attorney-at-Law


[1] Swanson, Tommy,  “The 5 Most Common Types of Medical Billing Fraud,” Business2Community, Jul. 28, 2012. According to the National Health Care Anti-Fraud Association (NHCAA), health care fraud causes financial losses in the tens of billions of dollars every year. NHCAA, “The Challenge of Health Care Fraud,” http://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx.