Health care providers with private practices in Georgia may encounter many situations where failing to follow proper procedure when it comes to billing could land them in hot water. In fact, as Cornell Law School's Legal Information Institute explains that certain actions could be health care fraud.
To prove fraud, a prosecutor would have to show that the provider intentionally deceived someone with a plan to cause damage. In the case of billing issues, the damage is typically financial. The someone could be a patient, but it could also be an insurance company or even the federal government that is defrauded, if the issue involves Medicare.
The National Health Care Anti-Fraud Association notes that one form of billing fraud involves charging for procedures that were not performed. This could be adding a procedure to an insurance claim that includes legitimate services. Or, it could be using patient information to create an entirely false insurance claim.
In some cases, billing fraud could seem like it is a way to help a patient. For example, insurance companies often do not cover procedures that are considered cosmetic. If a patient cannot afford the procedure, the doctor may suggest misrepresenting the treatment as a similar procedure that would be considered necessary so that the insurance would pay for it.
It is also health care fraud for a provider to unbundle services and charge for each one, even though the particular treatment should be billed as a single unit. Upcoding involves billing for a more expensive service than was actually performed. Fraud may also include other methods of changing billing to receive larger payments.