when it comes to billing and when it
comes to which is very commonly a factor
in a a health care fraud case. Um
whether the coder is being charged or
the biller uh actual medical billing
company is being charged or the lab
owner or durable medical equipment owner
is being charged for improper billing or
lack of medical necessity for the codes
that they are submitting. That’s always
going to be a focus of a healthc care
fraud prosecution. But when it comes to
sloppy billing versus actual fraud, the
focus is going to be criminal intent.
And that is really always going to be
the focus of a healthc care case.
Medicare and Medicaid and the services
such as health care, Medicare advantage,
part C that are providing these services
through private insurers, their rules
and regulations are changing all the
time in response to various loopholes,
individuals who are allegedly targeting
certain types of products um to maximize
reimbursements in a lawful and sometimes
unlawful way. But sloppy billing really
turns into fraud when it comes to actual
criminal intent. There has to be
knowledge, whether it be in the form of
a conspiracy with a co-conspirator
to accomplish a healthc care fraud.
There has to be knowledge that you are
in fact attempting at least if not
actually violating the rules of a
federal health care program. and you
have the intent to cause that program
loss. So, at the end of the day, like
most charges, even though healthcare
cases and cases involving improper
billing can be very sophisticated and
very complex, it still does come down to
criminal intent.