What Do You Consider A Medical Billing Fraud?

Medical billing fraud makes all of us increase healthcare costs. It is an attempt to receive payment fraudulently from and insurance provider. Medicare and Medicaid, due to their payment arrangements, are particularly sensitive to fraud.

With all the talk of health care reform by policymakers these days, that waste to reduce costs is receiving a lot of coverage. Looking at what is spent on Medicare and Medicaid, not to mention private insurance, there are plenty of billing fraud opportunities.


A patient visits the hospital to seek treatment for the sprained ankle, but the insurance provider is charged with a fractured ankle by the doctor. How do you do that?

This fraudulent practice was coined as ‘upcoding’ because your doctor or healthcare provider must attach a CPT code to each procedure performed – and that code dictates how big or small the bill will be. Since its often big insurance firms routinely handle thousands of computerized statements, many poorly coded procedures can easily be missed.

Ghost Billing

One of the most common types of fraud involves billing services that were not carried out. This type of fraud affects the costs of health care since it only increases costs by the fact that the charges are not justified, but millions of dollars are spent each year tracking and finding and preventing this fraud. The government has formed RACs (Revenue Audit Contractors), which are paying a percentage of fraudulent or illegal billing practices in the last three years.

This form of fraud not only has a substantial financial effect on the government but also affects a patient’s health insurance. False reports for operations that have never taken place remain on the patient’s medical record and therefore, may impact the insurance or the care of potential physicians.

Unbundling Service

Unbundling happens when a kit contract involves several procedures to be paid separately, thereby generating a higher invoice.

Unbundling is another type of upcoding called “fragmentation,” which usually affects patients who have Medicare and Medicaid, as they generally have different reimbursement levels for specific categories of frequently performed procedures like blood test panels to be sent to the laboratory. Healthcare providers who seek to raise income fraudulently will drop the special package prices and separately charge each part of the test.

Self Referral

Self-referral happens when a physician requests examinations for a patient refers to himself or a member of the staff by whom financial compensation is received in return for the review. For instance, a surgeon who suggests and promotes an operation that he or she conducts is illegal. This is to prevent the promotion of unnecessary procedures and the overuse of services in the law prohibiting self-referral.

Benefits in Hiring a Lawyer for Medical BillingFraud

You may be able to hold an individual or a health care provider responsible and compensate for medical expenses and other damages by filing a complaint.

  • A promoter of medical fraud has proven expertise and outcomes.

A specialist in medical fraud works mainly on cases of fraud. We are not just retired attorneys who are familiar with criminal law.

You should hire an attorney for medical fraud as he has a strong background in complex reimbursement regulations for Medicare and Medicaid, including Stark’s and Anti-Kickback Statutes. Check for the best health care fraud defense lawyers.

  • A prosecutor in the field of medical fraud knows the local court system.

A Medical Fraud Attorney’s knowledge of the local court system is one of the most significant advantages.

A Medical Fraud lawyer is familiar with the right people – the judge, prosecutors, the clerk’s court, and everybody involved in the law. His local relationships form a pattern of persuasion between judges and provide a strong reputation in his legal profession.

Due to his great accessibility and convenience in giving legal consultation, a medical fraud lawyer is favorable to a non-local person.

  • Your side is safe with a medical fraud lawyer.

Regardless of whether you have experienced physical, financial, or even emotional damage, a medical fraud lawyer will never give up and will work for you in a dispute.

A medical fraud lawyer tracks your history, previous experience, and related activities in the case. As he wants to win the case, he wants to develop a professional relationship with you.

Therefore, you are joined by a medical fraud lawyer at all stages of legal proceedings. He never gives up until a judge is convinced.

  • A counsel for medical fraud operates with caution and discretion.

A medical fraud attorney knows how to prevent dismissal and lose cases by ensuring the papers are correctly filed and pleadings and motions submitted on time before their deadlines.

You always retain their discretion by exercising privacy and are entirely responsible for maintaining your data and your case information.



Gary A. Wais is the senior managing partner for Wais, Vogelstein, Forman & Offutt and has almost 30 years of experience in his practice. He specializes in medical malpractice and medical misdiagnosis lawsuits, and has personally handled and resolved years of record-breaking cases in excess of $10,000,000.00. His most prominent case awarded $55 Million for birth injury.

The focus of his medical practice firm is in birth injuries, cerebral palsy, spine, brain injuries, and wrongful death. Mr. Wais received his J.S. from the University of Baltimore School of Law in 1983, and has been awarded many honors, including Maryland Trial Lawyer of the Year in 2012.

Gary A. Wais ,