When people discuss white-collar criminal charges, the focus is often on those who profit from fraudulent schemes. People assume that those who misrepresent their circumstances for financial gain might be legally culpable for those choices.
Unfortunately, sometimes professionals who do not receive any direct financial benefit from questionable company practices are left at risk of prosecution. For example, in the health care sector, coding and billing specialists only make a fraction of what licensed providers and office managers earn. They usually don’t receive any sort of profit sharing but rather a base salary or even hourly wages.
Despite the limited compensation offered to billing and coding specialists, they could potentially be at risk of criminal prosecution because of how the hospital or practice that hired them asks them to manage billing matters.
Certain billing practices could constitute fraud
The world of health care finance and medical billing is relatively complex. Individual medical facilities and practices have to negotiate arrangements if they intend to accept different kinds of insurance. Those medical companies then have to comply with the rules established by insurance companies and government insurance programs.
Particularly in scenarios where medical practices accept Medicare and Medicaid, accurate billing is of the utmost importance. Attempts to game the system and increase how much revenue the company generates might lead to allegations of fraud.
Training workers to unbundle discounted services is a sneaky way to optimize company revenue. Instead of honoring discounted rates for services typically provided together, practices try to charge extra by billing separately for each component of a discounted service.
Other times, companies might go so far as to instruct coders to alter the billing code to request reimbursement for a more expensive procedure that requires the same amount of time and equipment as the services actually rendered to the patient. Some medical practices might tell billers to submit billing requests for appointments that patients did not attend.
Any of these actions could constitute actionable fraud. The coder who inputs the information into internal computer systems or the biller who submits a reimbursement request to an insurance provider could end up facing criminal charges because of how they handle the medical billing process. Particularly in cases where workers did not receive any financial compensation for that behavior, they may assume that they aren’t at risk of criminal prosecution.
However, everyone involved in the fraudulent billing scheme could be vulnerable. Discussing company training and pending criminal charges with someone familiar with white-collar criminal defense can help those who fill support roles in the healthcare sector respond appropriately to pending charges.
Oftentimes, those accused of involvement in health care fraud may not realize the nefarious intentions of their employers. Workers implicated in fraud schemes may be able to avoid a conviction with the right response to the allegations that they face.
