How Fraudulent Billing Is A Form of Medical Malpractice

The definition of medical malpractice is often both simple and narrow in scope: it happens when healthcare practitioners cause “injury” to a patient by negligence or a lowered standard of healthcare. But the definition can take on or connote a more complicated, broadened scope in some cases — especially when healthcare providers put into place deceptive or fraudulent billing practices. Many medical malpractice attorneys will take on cases of fraud in this instance. But exactly what is fraud?

Fraud occurs when an individual or organization intentionally deceives the victim, usually with the intent to procure financial gain. You have certain rights. When those rights are violated in this way, fraud has occurred. Healthcare fraud can occur directly, or by proxy when insurance companies are involved. 

Fraud conducted with or without health insurance as a proxy occurs when a company chooses to bill a person more than required. This includes: bribing with kickbacks, unnecessary services, upcoding (or billing for more expensive services), duplicating claims, unbundling (or billing services separately when they are performed at the same time), unnecessary insurance, or billing for services a patient didn’t even receive.

The False Claims Act allows a victim of fraud to recover certain damages in court.

Because a person can be “damaged” financially, this type of fraud clearly fits the definition of medical malpractice. Many fraud-related claims are made, but few lead anywhere. This is because finding damning evidence of fraud can be extremely difficult. Many plaintiffs don’t realize that they need to “discover” all the required evidence before filing a lawsuit in court. That’s why so many of these lawsuits are dismissed out of hand.

The same is true of whistleblowers (who are protected by law when coming forward).

Another reason that fraud can be difficult to prove is the number of excuses that justify it in the first place. For example, let’s say a doctor orders more tests than a simple diagnosis might require. If he gets the diagnosis wrong, a patient might sue for medical malpractice after remaining sick. But even if he gets the diagnosis right, a patient might sue for fraud-related medical malpractice after receiving bills for services he didn’t even need.

Judges are understandably hesitant to award damages for lawsuits built on such shaky ground. 

That’s why whistleblowers are so beneficial to cases such as these. They know what’s going on in a healthcare provider’s environment — in the back room, so to speak — but they may be unsure of how to correct any misdeeds. They can file suit against the healthcare provider themselves, or they can approach a patient. Either way, the first step is easy: ask a medical malpractice or fraud attorney for legal advice. The rest is easy.