Many people are affected every year by healthcare fraud schemes. Billing fraud is one way this occurs, and it results in unnecessary and expensive costs for patients and physicians. Moreover, victims of billing fraud may not even be aware it is happening.
Many agencies and programs exist to fight fraud in the healthcare industry. While the Federal Bureau of Investigation (FBI) is the primary entity that investigates federal and private healthcare fraud claims, Arizona is also committed to preventing fraud through state legislation. Additionally, if you encounter a billing fraud case, an Arizona healthcare fraud defense lawyer with an inside perspective can help you determine a way forward.
An Overview of Billing Fraud
While billing fraud can happen at any medical facility, Medicare and Medicaid are particular targets. Billing fraud consists of three methods by which providers can extract money for false claims. The U.S. Agency of International Development – Office of the Inspector General defines those methods as the following:
- Fraud occurs when someone knowingly provides false information for the purpose of profiting financially or personally.
- Waste happens when there is unnecessary and excessive use of medical services and resources due to mismanagement or abuse.
- Abuse takes place when there is improper use of an item or service
Types of Healthcare Billing Fraud
Billing fraud happens all too frequently and has continued to increase in the United States. In medical practices, four types of billing fraud are known to commonly occur. A closer examination into each type shows the nature of each one.
Double Billing
Double billing is a type of healthcare fraud that happens when a patient’s service gets billed multiple times. Submitting more than one bill for the same service can lead to exorbitant costs for the patient.
Unbundling
Unbundling occurs when one service is billed with multiple individual codes rather than the one code that is supposed to include all relevant components, according to the American Medical Association (AMA). This can arise either from a simple misinterpretation or as an attempt to increase the price. Further investigation into an unbundling incident can clarify what triggered the action.
Phantom Billing
The American Patient Rights Association (APRA) reports that phantom billing takes place when a medical provider bills for services that weren’t rendered, are more expensive than they should be, or were not necessary for the patient. Phantom billing is known to occur each day and particularly targets Medicare. This type of billing fraud easily goes undetected.
Upcoding
According to the U.S. Department of Health and Human Services – Office of Inspector General, upcoding occurs when a patient is billed for a more expensive service than what they actually received. In this situation, a patient may go in and receive one service, but they are either billed for a different service or a related service that is at a different price point. This is punishable by steep fines and/or exclusion from federal medical programs.
Arizona Laws that Target Billing Fraud
Arizona has multiple statutes and programs in place to combat billing fraud. The state punishes healthcare fraud in a variety of ways, and statute 32-3208 requires any person who has been convicted of a misdemeanor or felony to report it to the regulatory board within 10 days of the filed charge so they may investigate further. Other statutes and actions taken by the state to penalize billing and healthcare fraud include:
- Anyone who is aware of fraud and accepts a benefit from it is guilty of a class 2 felony, according to Arizona statute 13-2310. A fraud conviction may result in no suspension of sentence, pardon, or probation prior to the sentence being completed.
- The provisions of statute 13-3713 outline the penalties for kickbacks by medical providers:
- Offering or receiving special rewards for patient referrals is a class 3 felony if the amount is more than $1,000, a class 4 felony if the amount is between $100 and $1,000, and a class 6 felony if the amount is less than a $100
- Investigations into fraudulent behavior can result in civil penalties and steep fines, according to Statute 36-2918. The state may investigate the fraud and execute a subpoena if prohibited acts are discovered.
Additionally, within the state’s criminal division, the Arizona Medicaid Fraud Control Unit investigates and prosecutes acts of healthcare fraud. They aim to root out false records and claims, theft, abuse, embezzlement, and illegal prescription usage. Because the state is committed to protecting citizens and ensuring they receive fair treatment, they work diligently to deter these white-collar crimes.
Criminal Trial Process in Arizona
In Arizona, the criminal process begins with an investigation by police that can lead to arrests and criminal charges. In the event the case goes to court, formal charges are filed, and both sides have the opportunity to present all relevant witnesses and evidence for a judge to make a ruling. Guilty parties will then be sentenced, but they can also appeal the decision at a later date.
How Legal Representation Can Help
The complexities of the healthcare and billing landscape can be confusing and overwhelming. As such, a skilled lawyer who is well-versed in the intricacies of federal and state healthcare fraud laws can be an invaluable asset. Navigating a white-collar crime is not the time to proceed on your own.
Hiring a criminal defense lawyer right away is recommended for navigating Arizona’s criminal trial process. A lawyer will investigate your case, build a strategic defense, speak on your behalf, provide advice, and so much more. Working with a lawyer can significantly impact the outcome of your case.
Let Suzuki Law Offices Fight for You
Facing a healthcare and billing fraud case is a serious matter, and the team at Suzuki Law Offices is committed to advocating for you and your rights. Our firm provides compassionate and unrivaled legal assistance to guide you through the process. Contact us today for a free consultation, and let us fight for you.
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