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Recent debates about health care coverage have drawn increased interest in the topic of health care fraud. Many people believe health care or Medicare fraud is committed by individuals who have low or no income and take advantage of government programs despite having the ability to work a better-paying job. On the contrary, the majority of schemes are advanced by organized crime rings and, in some cases, health practitioners and facilities. Medicare fraud can take many different forms and occurs in a variety of different medical settings. If you’ve been charged with this federal crime, discuss your case with an experienced health care fraud attorney in Miami immediately.

Billing for services not rendered

One of the most common types of health care fraud in Miami is billing for services not rendered. These cases involve medical providers who submit a claim to a private insurance company or government program for services the practitioner or facility never provided. Investigators compare patient records to the dates the billing record states the services were provided. Typically, when a staff provides a service to a patient, he or she will write down notes about the patient’s current condition and the medical service he or she needs. The absence of patient notes signals investigators that federal fraud may be at play.

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Waiving deductibles and co-payments

Government and private plans generally do not allow medical service providers and facilities to waive insurance deductibles and co-payments. Nevertheless, some health care professionals and facilities in Miami may be tempted to do so fraudulently because patients are more likely to seek services when their costs are lower. In addition to waiving patient co-payments and deductibles, some of these facilities will also add other false services to the patient’s claim in the interest of obtaining a larger payment from the insurance company with little or no out-of-pocket costs on the patient’s behalf. Most patients enjoy saving money; therefore, patients typically do not report these practices.

Billing non-covered services as covered

Most people in Miami are aware that they must check with their medical service provider to determine whether the procedure or medication they would like to receive is covered by their insurance policy or government program. Cosmetic surgeries are usually not covered unless medically necessary. Experimental drug treatments are also often not covered by standard policies. Some medical providers may engage in health care or Medicare fraud by billing the patient’s insurance provider for a covered service or procedure while providing another service or treatment that is not covered. The end result is the patient receives uncoverred treatment while the insurance company or government foots the bill.

Billing for unnecessary services

Health care and Medicare fraud does not always involve patients receiving the treatment they need or want at a more affordable price. In some cases, the standard of care the patient receives may become compromised. Some doctors and clinics subject patients to unnecessary tests and procedures in the interest of billing the insurance provider for a larger amount. This type of fraud may cause patients to spend time receiving treatments they do not need. The patient’s insurance premiums may even increase unnecessarily if it appears the patient is being treated for conditions for which he or she not been diagnosed. The process of running unnecessary tests may also delay the patient from receiving the correct effective treatment in a timely manner.

Misrepresenting location of services

There are some treatments patients may pick up from a doctor or pharmacist and administer to themselves at home. Injections and respiratory treatments are common examples. Practitioners and medical facilities are typically able to bill insurance companies for more money if they administer the treatment on location. Service providers and facilities sometimes defraud insurance companies by falsely claiming the patient received the treatment at the medical facility when, in fact, the doctor simply wrote a prescription and authorized the patient to administer the treatment at home. Always consult with a Miami Medicare fraud attorney immediately after being charged with a related crime.

Unbundling services at Miami medical facilities

Another form of health insurance fraud occurs when a health care provider bills each step in a treatment as a series of separate treatments. For example, a patient may need surgery for a dislocated shoulder. A practitioner commits fraud if he or she bills the insurance company for each step in the pre-op and surgical process as if the patient received separate therapies. This practice is termed “unbundling.” Medicaid and Medicare programs often pay a lower reimbursement to service providers for procedures that are incidental to surgeries. Therefore, to receive a larger payout, surgeons and facilities sometimes fraudulently attempt to create the impression that the procedures are unrelated to the surgery when, in fact, they were a necessary part of the surgical procedure.

Kickback schemes

Most people are familiar with the concept of how fraudulent kickbacks work. A Miami doctor may examine a patient who has a cough that is caused by an allergy. The doctor prescribes a drug to the patient, claiming the medicine will treat the patient’s cough. The patient researches the medicine and finds out the medication is a popular arthritis drug that is not designed to treat coughs. Further investigation reveals the pharmaceutical company is paying the doctor an incentive for every patient to whom the doctor prescribes the drug. Not only do kickbacks result in patients potentially receiving therapies that are of no medical benefit, but these schemes compromise the perceived integrity of the medical community and level of trust patients have for their care provider.

Aggressive pursuit and prosecution in Miami

The increased scrutiny of national health care costs has led to a heightened awareness of fraudulent practices. Therefore, the government aggressively pursues individuals and organizations that are involved in fraudulent health care or Medicare schemes. In some cases, a billing error may occur as a result of an unknown mistake while in other cases, individuals who merely work for an organization that is involved in a fraudulent scheme may find themselves accused of committing a serious crime. A Medicare or health care fraud defense lawyer in Miami like David Joffe can help individuals and medical facilities fight serious federal fraud charges.

Serious federal cases only.

Serious federal cases only.

Serious federal cases only.

Serious federal cases only.

Serious federal cases only.