Why Might I Be Accused of Billing Fraud?

As a physician, you may expect the Health Maintenance Organization (HMO) or otherwise the government to conduct frequent audits on your billing practices. And if you are wrongly accused of billing fraud after such an audit, then you may be facing serious penalties either monetary or non-monetary, or both. Follow along to find out why you might be accused of billing fraud and how a proficient New York billing fraud attorney at Walker Medical Law can come to your defense.

Under what circumstances might I be accused of billing fraud?

It is easier to be wrongly accused of billing fraud than you may initially realize. That is, you may be wrongly accused under the following circumstances:

  1. An auditor looks at a very small sample of your billing to come up with a percentage that was over-billed.
  2. An auditor assumes that this percentage applies to all of your billing over as long as six years.
  3. An insurer sends you a demand letter whereby they order you to return the total amount that you have allegedly over-billed over as long as six years.

As a specific example, say that an auditor looks at 30 charts and found that you over-billed an insurer by 30 percent. Well, an insurer will assume that you have been over-billing them for the last six years; so if you billed them $500,000 total, they may demand that you return $150,000 total.

What happens if I am found guilty of billing fraud?

If you believe that you have been wrongly accused of billing fraud, you may be unsure as to whether it is worth fighting back. For most cases, it is recommended that physicians attempt to settle the claim with the insurer for the lowest possible number.

With this, you will need to retain your own auditor, who will essentially audit the insurer’s auditor. Your own auditor will be able to argue that the original audit was unreliable and not indicative of your overall billing activities. What’s more, they may even be able to bring forward instances in which you under-billed the insurer. The hope with this is that the insurer will drive down the percentage of over-billing that they are demanding to be reimbursed for.

But if you do not think that a reasonable settlement can be accomplished, you may consider disputing it instead. Before you kickstart your legal action, you must review your contract with your insurer. This is because there may be an arbitration clause that states that your dispute will be determined by an arbitrator instead of a judge or a jury. With this, you will need to retain your own attorney.

It would be best if you did not have to go through these settlement proceedings or fight alone. Instead, you should seek the assistance of one of the talented OPMC/OPD misconduct defense attorneys from Walker Medical Law. Contact our firm today.