Medical care providers who accept Medicaid, Medicare, or private insurance must comply with myriad regulations regarding when they bill for patient services, how they bill for patient services, and what documentation they must maintain in order to prove patient services were medically necessary. If a determination is made that a provider was not following regulations, the provider could be faced with accusations of criminal insurance fraud. This, in turn, could put a medical license at risk as state medical boards will take disciplinary action against doctors who have committed insurance fraud crimes.
If you are subject to an insurance audit, a Medicaid audit, or a Medicare audit, you need to vigorously fight to avoid any claims you have committed fraud. It is best to try to avoid a finding of fraud at the audit stage so the case against you does not progress to accusations of criminal insurance fraud. Once allegations of fraud have been made, you will need to both defend against any criminal fraud proceedings and address the threat to your medical license which comes with a finding of fraud. An attorney can help you to fight on both fronts to protect your career and your finances.
Medical License Defense After Accusations of Insurance Fraud
The number of doctors being subjected to audits for potential overpayments has been growing, especially for medical care providers who accept Medicaid or Medicare. Centers for Medicare and Medicaid Services describes a Medicare Fee for Service Recovery Audit Program which has been created to "identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries." There is a similar audit program in effect for Medicaid as well, while private insurance companies also conduct audits.
One possible result of such an audit is a criminal referral if fraud is identified. CMS makes clear criminal fraud can impact a person's medical license, as can a refusal to return payments when an audit has been conducted and irregularities are discovered. Coping with the burdensome Medicare, Medicaid, or insurance audit while also facing a threat to your right to practice medicine can be a major issue for care providers.
Unfortunately, there are many situations where services are medically necessary but where auditors determine you failed to prove this or did not correctly document services provided. Complying with all Medicare and Medicaid rules for medical records is time-consuming and difficult, and many care providers are not 100 percent in compliance. Mistakes and technical failures in your documentation regarding care provided should not be justification for claims of fraud against you and should not put your medical license at risk. It is imperative you get the help of a qualified medical license defense attorney when responding to any accusations of fraud or wrongdoing so you can keep your license to practice medicine safe.