When a Texas medical care provider is accused of not following the regulations they are required to follow in order to accept either private insurance, Medicare, or Medicaid, they have entered a potentially career-ending scenario. A medical care provider who has been determined to have committed such violations of regulations can face further problems, including accusations of criminal insurance fraud. And when the Texas Medical Board learns of this finding of fraud, it will proceed to take its own disciplinary action against the practitioner, up to and including revocation of their license to practice medicine.
The regulations a medical provider must follow for insurance purposes are generally clustered around issues of billing for patient services: namely, how is the bill issued, and the forms of documentation that must be kept attesting to the medical necessity of the services provided.
Any audit by Medicaid, Medicare, or a private insurance company must be met head on as swiftly as possible. This is so that the best possible case can be mounted. False fraud allegations can occasionally be dealt with during an audit. If not, then comes the charge of criminal insurance fraud, as well as the launching of an investigation, hearings, and a decision by the Texas Medical Board meting out punishment.
And the truth is, the number of audits in search of possible overpayment has been increasing in recent years—particularly for providers accepting Medicare and Medicaid. This has meant an increased number of irregularities discovered by audit, resulting in more criminal referrals being made and more criminal charges being levied.
Needless to say, medical providers find this situation onerous on multiple levels.
This is particularly the case when insurance auditors override a doctor’s performance of a service as “unnecessary.” At the same time, the doctor—with their intimate knowledge of the patient and the case—knows it to have been necessary indeed. A necessary procedure may be deemed otherwise because the provider allegedly did not document the procedure correctly. We believe a small mistake in documentation should not stand as the basis for a provider to be accused (more or less found guilty) of fraud.
BERTOLINO LLP handles medical licensure, grievance complaints, ethics, and other important professional licensing issues. If you have received a licensing complaint, BERTOLINO LLP can help. To best serve our clients, we have offices in Austin, Houston, and San Antonio.
Contact us today or call (512) 717-5432 and schedule a case evaluation.