Health care fraud often involves fraudulent billing for services that were never provided or overbilling for provided services by unbundling procedures or upcoding services. Sometimes, though, a practitioner or health care provider can be accused of fraud even if he or she only bills for the services and procedures performed.
Billing for unnecessary procedures or excessive services is considered a violation of federal health care fraud laws, and as such, it carries the possibility of federal criminal conviction. Being accused of making “unnecessary” medical decisions on behalf of your patients can be frustrating; being charged with a crime for your decisions to provide medical care is frightening. A Virginia federal health care fraud excessive services lawyer can offer you support and a defense in a challenging time. Call today to schedule a free consultation with a Virginia federal healthcare fraud attorney to discuss your case.
Excessive services health care fraud occurs when a provider orders unnecessary medical services or procedures simply to be able to bill the patient, health insurance provider, or Medicare for the service.
The Code of Federal Regulations (CFR) refers to the sufficiency of medical care in 42 CFR 440.230. This section states that “each [health care] service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.”
If the services rendered, equipment provided, procedures performed, or tests ordered are beyond a “reasonable” scope to effectively diagnose and treat the patient, the provider may not bill for these “excessive” and “unnecessary” procedures.
Being called into question about your professional decision-making and the plan of care you have established for your patient can be infuriating. To be accused of fraud because you are thorough in providing for your patients’ health care needs seems unfair. If you are accused of fraud, however, the situation involves more than your professional reputation. Criminal consequences may be at stake which is why contact with a federal healthcare fraud excessive services lawyer in Virginia is so important.
Health care fraud, including excessive billing and unnecessary services, is a federal offense. Federal law in 18 US Code 1347 makes it a felony to “knowingly and willfully” defraud or attempt to defraud a health care benefit program. Ordering unnecessary tests and procedures, or providing excessive services for no medical benefit other than to allow extra billing can be considered an act of healthcare fraud.
Federal conviction of health care fraud is punishable by a maximum sentence of 10 years in prison. However, if a patient is harmed or dies as a result of undergoing a medically unnecessary procedure as a means of perpetrating fraud, the maximum penalties are significantly increased: 20 years for injury and life in prison for death.
The Journal of the American Medical Association (JAMA) (pdf) estimates that nearly 10 percent of the nation’s $3 trillion health care expenditure is lost to fraud. In an effort to cut down on waste in U.S. health care, the federal government vigorously prosecutes those accused of various acts of fraud, including excessive billing. When confronting fraud charges brought by the U.S. government, it is important to have a Virginia federal health care fraud excessive services lawyer as your ally.