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Examples of Medical Billing Fraud

The Association of Certified Fraud Examiners names popular healthcare fraud schemes, including billing for unnecessary services, over-diagnosing and billing for services not rendered. 

Each of these instances needlessly charges the patient and brings more revenue to the provider.

In most healthcare facilities, a separate department takes care of the billing to the patient. The employee working in the billing department could inadvertently enter an incorrect billing code, charging the patient for a service he or she did not receive.

This charge could be less or more than the usual price of the service the patient actually received. While this occurrence is unintentional, it should still be brought to the billing department’s attention. Thankfully, more often than not, over-charging is due to simple human error.

Unfortunately, there are instances in which the patient is over-charged on purpose. Take for instance a patient who has had a surgical procedure and is charged for each individual tool and supply used during surgery.

These items are normally charged as one item, which saves the patient money, sort of like buying the combo meal at a restaurant rather than purchasing the burger, fries and drink separately. A facility might unbundle this surgical “combo deal” to receive more money from the patient or insurance provider.

How To Report Medical Fraud? 

Abusive billing should be brought to the facility’s attention immediately. Go through the normal channels of reporting errors in billing, beginning with the billing department. If you have no success here, request the contact information of the facility’s Chief Financial Officer.

Sometimes, just requesting this information is enough to rattle a billing employee into action, but if not, follow through with the threat of going to the CFO. If you are uncomfortable doing so, contact a medical billing advocate to do this for you – they exist to help you through situations such as this.

If you are a participant in the Affordable Care Act, you can report suspected fraud by calling 1-800-318-2596. If you are covered by Medicare and your billing statements do not match, first contact the provider for answers. The billing department should try to help you understand anything on your bill that does not make sense to you and correct any billing errors. Report suspected Medicare fraud to 1-800-632-4327.

All too often, it’s necessary to be persistent with the billing department in righting any wrongs on a medical bill. If you have private insurance or have been billed personally for exorbitant fees, you may need the assistant of a consumer attorney. If you are not satisfied after reaching out to the billing department or if any billing issues are left unresolved, contact our office today to see if you have a case of medical billing fraud. 

All consultations are free and we pursue all incurred attorney fees from the medical facility with no charge to you, if we decide to take your case.

Case Example

"As a clinician, myself, I am familiar with the stringent codes and ethical boundaries that should be upheld in billing patients. That is why I was extremly shocked when we took our 10 year old son to a walk in clinic near Kernan Blvd and Atlantic Blvd, for a sore throat and were later billed nearly $5,000 for that 15 minute consultation.

The doctor performed absolutely no tests and actually misdiagnosed my son with Strep (didn't do any cultures), and prescribed a general antibiotic which I did not give to my son as his fever and sore throat had subsided completely by breakfast next morning.

I contacted Memorial ER directly and also my insurance provider, Humana, but both refuse to adjust this bogus bill or even provide billing codes to back up their fees.

It is dissapointing, but it seems that For-Profit Medical Centers often refuse to work with patients directly. I knew then that I would require a Consumer Justice Law Firm to handle the case.

Parents shouldn't be afraid to take their child to a medical facility for fear of trumped up bills!" - Jacksonville Mother/Victim of Medical Billing Fraud

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