What To Do If Your Healthcare Business in Facing Fraud Charges

In the United States, $4 trillion a year is spent on healthcare. As healthcare costs continue to rise, there is also an increase in healthcare fraud. An estimated $60 billion is lost every year due to fraud and abuse.

What is healthcare fraud?

Healthcare fraud is an intentional act of deceit by medical providers, patients or others trying to gain benefits or payments that they are not entitled to. The most common forms of fraud by a healthcare business include:

Submitting more than one insurance claim for the same service.
Billing for services or supplies that were not provided.
Unbundling: Charging and billing patients for the same service multiple times.
Upcoding: Charging for services that costs more than the service received.

Fraud can be both a state crime and a federal crime that may be punishable by:

Fees and fines of that could exceed thousands of dollars.
Jail or prison time.
Loss of professional licenses.
Loss of employment and difficulty finding other employment.
There can be other consequences, such as a damaged reputation.

What to do if your healthcare business faces fraud charges?

The FBI is the primary agency that investigates this type of fraud and may work together with other federal organizations and state agencies to identify and investigate fraud. Only a small percentage of healthcare businesses commit fraud.

If your business faces fraud charges, you should do the following:

Try not to panic. Do not try to hide anything. Do not do or say anything that could make you look guilty.
Seek legal advice immediately. The actions that brought about the fraud charges could have been the result of a mistake that was made, instead of an intentional act of fraud. Talk to your legal team or a trusted attorney who is experienced in dealing with healthcare fraud cases.
Gather all documents that may help prove your innocence. This could include billing or financial records and emails.
Only discuss the fraud charges with your attorney. Limit conversations about the charges, any possible settlement agreements, legal actions or potential litigation with other staff and employees at your business. Do not discuss the fraud case with anyone who could serve as a witness or family members and friends who may have limited knowledge about the fraud charges.

After being charged, how can your business move forward?

Identify and correct business practices that may have led to fraud.
Establish policies that prevent and identify fraudulent activity.
Ensure a system of compliance is in place.
Provide education to staff about fraud and how to prevent it.
Familiarize yourself and your staff with fraud laws and regulations.

Fraud can have severe consequences for healthcare businesses, patients, and the healthcare system. If you are charged with fraud, assist your legal team in gathering information to prove your actions were not intentional. Insurance and healthcare companies often change requirements for both services and medications, which can make it hard to know the most current regulations. Learn about warning signs that your business should identify and correct to prevent healthcare fraud in the future.