According to New York’s Penal Law § 177.20, individuals may face healthcare fraud charges if they knowingly submit a deceitful healthcare claim, resulting in receiving improper payments. If the fraudulent payments total more than $50,000 but less than $100,000, it constitutes second-degree fraud.
Medical identity theft
The act of medical identity theft occurs when an individual uses another person’s medical identity to obtain healthcare goods, services, or funds fraudulently. This white-collar crime typically involves the unauthorized use or theft of a patient’s medical identity information to bill public or private healthcare providers for services or goods. In some cases, perpetrators may utilize fictitious patient identities to obtain prescriptions or submit fraudulent bills for services that were never actually provided to the patient.
Upcoding
The term “upcoding” is not an official term. Still, it refers to the practice where a healthcare provider bills for a more complicated service than was provided to the patient or what gets documented in the patient’s medical record. For instance, a medical equipment supplier may submit a bill for a motorized scooter but only provide the patient with a cheaper manual wheelchair. A physician may bill an insurance company for a complex medical visit while the patient only receives a simple consultation. Healthcare professionals should bill only for services rendered at the level they provided them.
Kickbacks
Kickbacks occur when a physician receives some form of financial incentive, such as cash, equipment, or vacations, in exchange for referring patients to other medical professionals. While rewarding someone for generating new business is not inherently illegal, it may violate federal healthcare program regulations. For instance, it is likely legal if a physician receives payments from a medical testing facility for referring federal healthcare patients. However, the issue with kickbacks in the healthcare industry is that they can lead to physicians referring patients for unnecessary services, which can inflate the cost of federal programs. This can also impact a patient’s decision-making and create unfair competition.
The healthcare industry is highly susceptible to fraud and corruption, making it crucial to prevent such practices to ensure patients receive optimal care and the cost of healthcare remains reasonable.
