Health insurance billing fraud is often egregious and profit-driven. Professionals working at a doctor’s office or hospital use specific tactics to increase the company’s revenue. They unbundle medical services typically provided at a discounted, combined rate. They upcharge or submit billing requests for a more expensive medication or procedure than what the practice actually provided the patient.
The goal is to optimize company revenue at the expense of the insurance company. If the insurance program billed is Medicare or Medicaid, then the revenue comes at the cost of the taxpayers. Professionals accused of health insurance fraud may not have had profit-driven motives in every case. In some scenarios, the financial pressure generated by a no-show fee may inspire questionable billing practices.
No-show fees can be costly
It is relatively common for modern medical practices that set appointments to impose a penalty for failing to show up to the appointment or canceling with less than a specific amount of advance notice. Many medical practices require 24-hour notice to avoid a no-show fee.
The issue with that practice is that people never know when they might get into a car crash on their way to an appointment or have other challenges that arise with minimal warning. When a doctor’s office charges $100 or more for a missed appointment, a patient may struggle to cover those fees. They may even stop seeing a specific medical professional because of those costs.
What seems kind could be a crime
An older adult living on a fixed income and relying on Medicare coverage may not be able to afford a $150 no-show fee. The same can be true for a single mom who misses a Medicaid-covered well-child visit because she gets called into work.
A professional working in the billing department at a medical practice might decide to submit a claim to insurance as though the appointment actually happened. Their intention might be to protect a vulnerable patient from a significant financial setback.
However, their choices might actually constitute billing fraud. Phantom billing, or billing for appointments that did not occur, is a well-known form of health insurance fraud. Private businesses and those helping manage Medicare and Medicaid programs often watch carefully for signs of phantom billing.
People who simply wanted to save patients a bit of money might ultimately end up accused of defrauding insurance providers or even the federal government. Understanding how an act of kindness could lead to Medicaid billing fraud allegations or similar charges can help people as they respond to pending allegations. Even if patients ask to bill their insurance to avoid a no-show fee, professionals could expose themselves to legal risk by doing so.