Evidence Used in Health Care Fraud Cases

The evidence used to prove or disprove health care fraud goes far beyond billing information and includes physician’s private records, payroll, purchasing, and more.

Evidence Used in Health Care Fraud Cases

An accusation of health care fraud will initiate a federal investigation. These investigations yield a great deal of evidence like data and documentation. The evidence collected may paint a clear picture for the jury making it easier to convict someone of health care fraud. The type of evidence obtained can vary depending on the allegation. However, health care providers should be aware of the most common types of evidence and its uses.

Furthermore, any physician accused of health care fraud should speak with an attorney the moment they receive a subpoena requesting evidence. While a physician is required to comply, an attorney can help ensure protocols are followed and that the government is not over-reaching with their requests.

Billing and Claims Data

The most common evidence examined in a health care fraud case is the data collected from electronic billing and claims filed with the health insurance providers. Claims data shows critical information like:

●        Health care provider

●        Billing codes

●        Date of service

●        Amount billed

●        Billing date

●        Electronic submission and confirmation number

●        Claim status

This data might be isolated to focus on a single provider, patient, or any set of data that indicates fraudulent practices.

Patient Charts and Medical Records

Patient medical records are another potent source of evidence. Providers are required to document all services, medical records, conversations with the patient, and other pertinent information that justifies diagnostics, services provided, and billing.

Some items that these medical records could prove or disprove include:

●        Whether the services billed were noted in the chart and provided.

●        Whether the services or procedures billed coincide with the dates the patient was seen by the physician and their diagnosis.

●        Whether there is an absence of documentation – proving the services billed for were false.

●        Showing which provider saw the patient and other healthcare providers involved in that date of service transaction.

●        Determining the medical necessity of prescriptions, tests, and procedures.

Business Records

Non-patient records can also help prove or disprove health care fraud. They may show schedules where patients were assigned to specific doctors. They can also show what dates a physician was out of the office, hours they worked, payroll verification for work hours, and any medical equipment/supplies purchased by the provider compared to the claimed “used” supplies in billing.

Personal Records

When a physician or healthcare provider is suspected of fraud, their entire life becomes part of the investigation. Federal investigators may request personal records that will help prove fraudulent practices. An example of these personal records would be credit and debit card transactions to show if a provider was on vacation when a fraudulent billing took place.

The Importance of Counsel

Health care fraud allegations are extraordinarily complicated to defend. Therefore, any physician or health care provider accused of fraud should speak with an attorney immediately. It requires knowledge of the industry, experience in criminal law, and healthcare fraud experience to defend a physician properly.

If you are accused of health care fraud, be sure to meet with an attorney in your area and discuss your options.

Date Of Update: 25 April 2018, 01:55

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