Types of Healthcare Crimes: What are they?
Healthcare providers are subject to myriad laws and regulations and are required to report to an alphabet soup of state and federal regulators. A number of crimes are prevalent in the healthcare industry, many of which concern some type of fraud. Below, we identify some of the more common types of healthcare criminal activity. If you are a healthcare provider in California and have regulatory or legal concerns, or if you have any questions about a matter of healthcare or business law, call a dedicated California healthcare law attorney.
Upcoding and Coding Fraud
Medical codes are used by billing services to identify what services were provided and which medical professional provided them. Upcoding and other coding-related crimes occur when hospitals intentionally use the wrong code for a procedure, charging the patient or their insurance for a more expensive procedure than that actually performed or for the services of a more expensive professional (such as a code indicating the presence of a physician instead of a nurse practitioner).
Medicare, Medicaid, or Insurance Fraud
Healthcare providers commit fraud when they bill insurance providers for services that were never performed, overbill for services that were performed, or otherwise upcharge insurers for fraudulent reasons. Different laws and punishments apply when defrauding private insurance companies than those that apply when defrauding Medicare or Medicaid.
It is also illegal for healthcare providers to treat customers receiving Medicare and Medicaid differently from other patients. For example, a pharmacy that charges patients significantly more if they are on Medicare or Medicaid but offers a discount to patients who are not would be guilty of Medicare fraud for overcharging the government.
Hospitals and other healthcare providers cannot maliciously trick patients into accepting treatments unrelated to or superfluous to their actual condition. It is illegal for a healthcare provider to, for example, give a patient tests unrelated to their condition, subject a patient to multiple redundant tests, or undertake an unnecessary medical procedure without proper explanation to the patient.
Anti-kickback laws and regulations prohibit physicians from obtaining anything of value in exchange for using certain medical services or products. If a physician accepts gifts of money, jewelry, or other items in exchange for, for example, prescribing certain medications, they might be committing a kickback violation.
Patient Privacy Violations
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets certain standards concerning the protection of confidential patient medical information. Healthcare businesses are required to provide proper training to physicians and other healthcare staff concerning how to protect patient information and the consequences of failing to do so. They are also required to implement information security procedures and technology to protect patient privacy.
Healthcare professionals who violate HIPAA rules could face a number of penalties including criminal charges. Criminal sanctions may be on the table even for violations caused by criminal negligence as opposed to intentional dissemination of confidential patient information.
Protect Your California Medical Practice
For assistance with matters pertaining to healthcare regulations, criminal liability, healthcare employment disputes, healthcare mergers and acquisitions, licensing, or any other healthcare legal issue, contact the Law Offices of Art Kalantar in Los Angeles or California statewide at 310-773-0001.