A nurse practitioner is facing up to 75 years in prison for wrongfully billing Medicare: Can you accidentally commit billing fraud?
Key Takeaways
A Florida nurse practitioner faces up to 75 years in prison for conspiracy in a Medicare scheme.
Healthcare providers can face extreme consequences for billing fraud—from fines to jail time.
To be convicted of billing fraud, a jury must prove intent.
A Florida nurse practitioner has been convicted of healthcare conspiracy in a $200 million Medicare fraud scheme. She wrongfully billed Medicare for medically unnecessary treatments and pocketed $1.6 million of stolen money.
According to the Department of Justice, the nurse practitioner, Elizabeth Hernandez, participated in a broader scheme in which telemarketing companies contacted Medicare patients to persuade them to request unnecessary braces and tests, which were then billed to Medicare, CNBC reported. In addition to conspiracy to commit healthcare fraud, a federal jury convicted Hernandez of healthcare fraud and making false statements. Now facing a maximum prison sentence of 75 years, her fate will be determined on December 14.[]
Can you accidentally commit healthcare fraud?
To charge a physician with healthcare fraud, a jury has to prove that the physician acted with specific intent or, as the law states, “knowingly and willingly,” to defraud any healthcare benefit program.[]
So, while not impossible, most physicians don’t have to worry about accidentally committing healthcare fraud. However, there are less significant mistakes that physicians can make in billing processes that could get them into trouble.
Helene Beilman-Werner, President & CEO of Zymeda Provider Solutions in Moreno Valley, CA, a consulting company that guides physicians through the financial side of healthcare, says that most of her clients’ billing mistakes are not purposeful but are due to ignorance.
“Doctors spend a lot of time learning how to be doctors and take care of patients, but they don't learn about really running the ‘business’ of their practice,” Beilman-Werner says. “The fact of the matter is: it is a business, and in order to be able to take care of people, you need to get paid for the services that you provide.”
Beilman-Werner started Zymeda Provider Solutions about 12 years ago to support physicians navigating healthcare billing. Having previously worked on the payer side of healthcare, she says she “saw what providers weren't doing correctly on the front end—which resulted in us either denying, or deferring, or requesting more information on the back end.” She created Zymeda to help get providers on the right track, which meant connecting them with the money they were entitled to.
“The premise is: Doctors should get paid for every single thing that they do, but with a high degree of integrity [and] for not a penny more and not a penny less,” Beilman-Werner says.
On rare occasions, Beilman-Werner has dealt with doctors who submitted purposeful, fraudulent billing claims. On these occasions, she has terminated that physician’s relationship with the company, she says.
Working through complicated billing codes
Beilman-Werner notices that, when working with other clients, some mistakes arise in note-taking and in specific codes for treatments. When billing Medicare, Medicaid, or private insurance, providers will need to submit codes to companies to be reimbursed for treatments. Making sure that these codes are accurate and that they reflect the severity of the treatment provided is crucial.
“The codes that are being used can really get a doctor into a lot of trouble,” Beilman-Werner says. “That is far more common, I believe, than true fraud.”
Submitting the wrong code could lead to physicians receiving a retraction letter, where—depending on what mistake was made—they may owe money to the company. In unfavorable situations, which tend to involve other factors like intent or multiple occurrences, a physician could be flagged by the insurance company, subjected to an audit, and/or fined heavily, Beilman-Werner says.
While they don’t have to go overboard, physicians may want to assess their note-taking processes to see if they accurately describe their work with patients and if their billing codes reflect this. In case a mistake is made, note-taking can serve as evidence for the work that was provided. Physicians can also make mistakes that cause them to be underpaid. Properly assessing their claims may help avoid this, too.
For those with more questions about the process, Beilman-Werner says it can be helpful to talk in person or on the phone with an insurance representative or outside consultant.
“Doctors are really, really smart people, but they need to really become more educated on what their rights are as a provider,” Beilman-Werner says. “If it's a covered benefit and everything was done correctly, there's no reason not to get paid.”
What this means for you
After being convicted of conspiracy and healthcare fraud for her participation in a Medicare scheme, a Florida nurse practitioner could face up to 75 years in prison. Insurance billing can be complicated, so mistakes are not uncommon. To be convicted of healthcare fraud, it must be shown that a provider acted with intent.