What Happens if I Am Accused of Billing Fraud as a Doctor?

In New York City, Westchester County, Long Island, and the greater metropolitan area, doctors and healthcare professionals can face serious consequences if allegations of billing fraud arise. These allegations can result in audits, Office of Professional Medical Conduct (OPMC) investigations, demands for repayment, and even potential criminal exposure. Unfortunately, even honest billing errors can have detrimental impacts on your reputation and ability to continue practicing. The following blog explores what you should know about these difficult matters.

What Happens if I am Accused of Billing Fraud as a New York Provider?

Doctors have a lot on their plates. Rather obviously, their primary concern is the well-being of their patients. Fortunately, most doctors in New York City and throughout the country are dedicated to ensuring their patients are provided with only the best care possible.

However, once a doctor is done treating a patient, his job is not entirely done. After treating a patient, a doctor is responsible for billing that patient properly. When the doctor overcharges his or her patients, there is a very good chance that he or she will face serious consequences as a result.

Of course, this can sometimes be a simple mistake; however, if you have recently been charged with billing fraud, you are most likely very concerned about your future as a doctor.

Allegations of medical billing fraud can arise from:

• Audits conducted by insurance companies
• Reviews by Medicare or Medicaid
• Complaints from patients
• Continued billing irregularities
• Discrepancies in insurance claim coding

In New York City and across the state, allegations of billing fraud are taken seriously, as they often involve claims of fraud, patient protection issues, and even potential misconduct.

What Does It Mean if I’ve Been Charged With Billing Fraud?

Essentially, patients should know what they are going to pay for a service or medication. When a patient, or his/her insurance company, notices that the price of the service/medication was higher than usual, you may face charges of billing fraud as a result.

Whether this was an honest mistake or not, it can have very serious repercussions. From here, there is a very good chance that the insurance company will audit your practice to learn more about the overcharging and whether it is a widespread occurrence.

You may face either a prospective billing audit or a retrospective audit. A prospective billing audit is performed by someone on your staff before the claim is submitted by the paying patient. A retrospective audit is when errors are found after a claim has been submitted.

Common Examples of Medical Billing Fraud

• Submitting false bills to insurance companies
• Billing insurance companies or patients twice for the same service
• Misrepresenting diagnoses or procedures
• Repeatedly using incorrect insurance billing codes
• Upcoding medical services to receive higher reimbursement
• Billing insurance companies or patients for services never provided
• Providing misleading billing statements to patients

What Types of Billing Audits Can Doctors Face in New York?

Healthcare providers in New York who are accused of billing irregularities may be subject to an audit conducted by insurance companies, healthcare organizations, or even government agencies. The primary purpose of these audits is to determine whether or not billing errors are honest mistakes or if they are part of a pattern of fraud.

Prospective Billing Audits

• Occur before a claim is fully processed
• Review the accuracy of the submitted code before a payment is issued
• Generally conducted internally by the insurer
• Can identify compliance issues early
• Can reduce exposure to larger regulatory bodies

Retrospective Billing Audits

• Occur once a claim has been submitted
• Examine claims that have already been paid
• Can involve insurance companies or larger agencies
• Can trigger larger investigations into a practice
• May result in repayment demands

Can Allegations of Billing Fraud Result in an OPMC Investigation?

If you are charged with billing fraud, there is a very good chance that you will be subjected to an investigation by the Office of Professional Medical Conduct (OPMC) to determine whether you are responsible for alleged misconduct. If investigators believe that fraudulent billing occurred, healthcare providers may face:

• Professional disciplinary actions
• Restitution and repayment
• Potential criminal investigation
• Increased scrutiny from insurance companies
• Potential license suspension

Potential Consequences of Billing Fraud Allegations

• Demand for repayment
• Increased insurance disputes
• Loss of patients
• Civil penalties
• OMPC investigations
• Loss of employment
• Difficulty securing future employment
• Potential criminal charges

Contact Our Experienced New York City Healthcare Provider Defense Firm

When a medical professional is accused of misconduct, they must retain strong legal representation. This includes allegations arising from claims of fraudulent billing practices. If you require a medical law attorney for your legal matters, call Paul E. Walker, an experienced New York City OPMC & OPD Lawyer. Please contact the Walker Medical Law firm to set up a free initial consultation.