Medical billing practices are subject to numerous state and federal regulations. Particularly when a hospital or other medical facility accepts government insurance programs, including Medicaid and Medicare, careful adherence to all regulations is crucial.
Health care providers, coders and billing specialists are among those who may become aware of questionable or outright illegal medical billing practices. Those individuals may have the option of acting as a relator. A relator is a kind of whistleblower who files a lawsuit against their employer under the False Claims Act.
A relator takes legal action based on inappropriate billing practices by filing a qui tam lawsuit. In return, they received protection from retaliation and compensation if the lawsuit is successful. What type of billing behavior may warrant a qui tam lawsuit?
1. Upcoding
Upcoding is one of the most common forms of billing fraud. The healthcare professional providing treatments or a billing specialist may input inaccurate information when billing for services provided. They bill for a more expensive procedure or treatment than the one provided to the patient.
2. Billing for missed appointments
Many health care practices have cancellation policies. They may impose a fee on patients who do not provide adequate advance notice before canceling an appointment. The goal in such scenarios is to limit last-minute cancellations and optimize scheduling practices.
Unfortunately, patients do not always have the resources on hand to cover cancellation fees. They might ask health care providers to bill their insurance even though they failed to attend an appointment. Doing so can constitute fraud and may lead to qui tam lawsuits if it becomes a regular practice.
3. Unbundling
Individual health insurance companies and government insurance programs negotiate specific reimbursement rates with health care providers. Professionals and facilities that accept certain types of insurance generally must accept specific reimbursement rates for those services.
It is common practice to combine or bundle services usually provided together and to bill for them at a discounted rate. Intentionally separating bundled services and billing for each one separately can maximize how much the company earns from a single appointment. However, it is a form of fraud that overcharges insurance programs.
Professionals who become aware of illegal and inappropriate billing practices may need to take action by filing a qui tam lawsuit. Reviewing company practices at length can help whistleblowers determine if they have adequate evidence to take the matter to court. Those who report company misconduct can improve company practices and may even qualify for compensation if they prevail in court.
