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Doctors: 3 ways medical billing fraud charges can come about

Medical identity theft can take a long time to come to light, and physicians are as much at risk as patients. Once someone discovers a fraudulent scheme, an investigation may ensue, and a doctor's career and reputation could be in jeopardy.

Government agencies track incidents of provider medical identity theft. They have found that fraudsters use two main approaches to carry out their schemes, and doctors may even set the stage for their own trouble.

1. Fake orders

One approach crooks employ is to use medical identifiers to make it seem that a provider referred patients for additional services, including diagnostic testing, durable medical equipment such as wheelchairs, or home health care. An example is the owner of a durable medical equipment company who received a federal prison sentence because he billed Medicaid for medical supplies that he did not deliver. To do this, he used physician medical identifiers.

2. Fraudulent billing

Another approach used by fraudsters is to use medical identifiers to make it appear that a doctor billed directly for certain services. An example of this kind of fraud was a woman who used the medical identifier of a New York doctor to charge for services that were never provided. The services were billed to a New Jersey Medicare Part B carrier. The woman got away with this for nearly three years before being caught and sentenced to prison.

3. Careless behaviors

Physicians sometimes set themselves up for potential trouble by allowing misuse of their medical identifiers. They might, for example, sign referrals for patients they do not know. They may sign a blank referral form or a Certificate of Medical Necessity for a patient who does not actually need the service or supplies indicated.

Health care providers need to be aware that they may be liable for such actions, even if there is no other evidence of fraud. If doctors worry about the possibility of fraud or that they may have acted unwisely, they may benefit from legal counsel.

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