3 medical billing practices that can lead to fraud charges

On Behalf of | Nov 27, 2023 | Fraud

Providing patient care is the service that medical professionals offer. Frequently, they do not receive payment for those services directly from patients. Instead, they bill insurance companies. Sometimes, the party paying insurance claims are state insurance programs.

Both Medicaid and Medicare offer taxpayer-funded support to those in need of medical care. Medicare provides coverage for those past retirement age, while Medicaid offers need-based coverage to those with below-average income. Particularly when a facility or medical practice accepts government insurance, it is crucial to avoid mistakes and violations of the contract with the insurance provider during the billing process. The three actions below could all potentially lead to the criminal prosecution of billing specialists and others affiliated with a medical business.


Upcoding is the technical term for billing for a service more expensive than the one actually provided. Sometimes, there are similar treatment options that require the same amount of time and the same equipment but have vastly different reimbursement rates. Although it may seem harmless to enter the billing code for the more expensive procedure, it can cost insurance providers thousands. Upcoding could trigger criminal charges if the practice eventually comes to light.


It is common for insurance providers, including Medicaid and Medicare, to negotiate discounted rates for certain services typically provided together. Unbundling occurs when someone separates each aspect of a medical service and bills for them separately to charge the maximum amount of money possible. Unbundling is both in violation of the contract between the insurance provider and the medical facility and a form of fraud. Charging more than an insurance provider agreed to pay for certain services can lead to complications when renewing the provider’s contract with the insurance company in the future and possibly prosecution.

Charging for canceled or non-existent appointments

Some medical practices assess a cancellation fee when patients do not show up for their appointments or cancel with minimal advance notice. They do this to deter people from scheduling an appointment and then wasting the time of the professional who expects to see them. Although it is legal to hold patients accountable for visits they did not attend, it is illegal to bill insurance providers for an appointment that did not occur. Both canceled appointments and fabricated appointments that someone did not schedule could lead to billing fraud allegations against an individual or multiple employees working at a medical practice.

Workers who never directly profit from these practices could still end up implicated in a fraud scheme and facing prosecution. Learning more about how seemingly minor billing adjustments can break the law may help people avoid mistakes that put them at risk of prosecution. With that said, if an innocent party is accused of wrongdoing, there is no shame – and a lot of wisdom – in seeking legal guidance as quickly as possible.

FindLaw Network
Gary Jay Kaufman
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