When patients complain that a physician performed an unnecessary procedure, an insurance provider may suspect fraud. The company may investigate, and based on the results, refer a doctor to law enforcement officials.
As described by the Insurance Information Institute, a health care provider might submit a code that pays more than the service actually performed. Submitting claims for expensive diagnostic tests may also trigger an investigation. In some cases, a doctor charged with insurance fraud may plead no contest to obtain a lesser sentence.
Investigations have increased
Since the Affordable Care Act of 2010, efforts to combat fraud have increased. Artificial intelligence looks for false statements on applications to participate in government-funded insurance programs.
When a health care provider enrolls in a public program, the stakes become higher to avoid billing issues and errors. Software designed to uncover instances of waste, fraud or abuse may lead to criminal charges.
A conviction may result in severe penalties
Convictions may come with serious consequences, such as a prison sentence and restitution. After a California surgeon pleaded no contest to insurance fraud, a judge ordered him to serve a three-year probation sentence, pay $2.9 million in restitution and perform 1,000 hours of community service.
As reported by U.S. News and World Report, the doctor allegedly participated in a medical fraud ring and submitted claims for unnecessary services. The doctors involved reportedly performed cosmetic surgeries and billed insurance providers for procedures such as colonoscopies and hysterectomies.
One of the most common types of insurance fraud consists of submitting a reimbursement claim for services that a patient did not receive. With complex billing procedures, however, mistakes often occur. A physician may then require a legal defense to counter a prosecutor’s allegations of fraud.