Legal Considerations for Healthcare Billing

Billing to the United States government presents a unique set of legal requirements for healthcare professionals. Physicians who participate in federal healthcare programs like Medicare and Medicaid are subject to strict billing regulations. Even inadvertent errors can lead to severe legal consequences, including criminal charges. Understanding these laws and the potential risk of noncompliance is crucial for healthcare providers.

When the federal government is paying for items or services rendered to Medicare or Medicaid beneficiaries, federal fraud and abuse laws apply. Healthcare professionals influence what services patients receive and are responsible for the documentation of those services. That documentation is the basis for bills sent to insurers, and ultimately, the Government’s payment of a beneficiary’s medical claims.

If a physician knew or should have known that the submitted claim was false, the attempt to collect unearned money constitutes a violation. Federal fraud and abuse laws include the following:

• False Claims Act (31 U.S.C. §§ 3729-3733)
• Anti-Kickback Statute (42 U.S.C. §§ 1320a-7b(b))
• Physician Self-Referral (Stark Law).
• Exclusion Statute (42 U.S.C. § 1320a-7).
• Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a).

These laws aim to prevent improper billing practices and financial incentives that could compromise patient care. These laws further grant powerful enforcement tools to federal agencies to penalize violations, ranging from civil fines to criminal charges.

The government can audit claims and investigate providers when there is a reason to suspect fraud. Unusual billing patterns or reports from others, including staff, competitors, and patients, may raise suspicion of fraud and abuse. If you’re a doctor who bills government healthcare programs, compliance with these rules and procedures is critical, as violations can lead to severe legal consequences.

One of the most critical aspects of government payer compliance is coding and billing insurers accurately for services rendered. Physicians may inadvertently engage in practices that violate federal billing regulations. Common billing violations include:

• Upcoding: Billing for more expensive services than those actually provided.
• Unbundling: Separately billing services that are typically bundled together.​
• Unnecessary Services: Providing services that are not medically necessary to increase reimbursement.​
• Kickbacks: Receiving or offering remuneration for patient referrals.
• Billing for services that an improperly supervised or unqualified employee performed.

In addition to maintaining compliance with billing regulations, these laws set forth requirements for maintaining accurate patient records, protecting patient privacy, and more.

Given the complexity and severity of potential penalties, healthcare professionals who find themselves under federal scrutiny for billing practices should seek the counsel of a federal criminal defense attorney as soon as possible. Physicians must be vigilant in adhering to federal billing regulations to avoid severe legal consequences. Understanding the legal framework and implementing proactive measures can safeguard against inadvertent violations and protect your practice’s integrity. Contact us to schedule a consultation.