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3 Common Allegations in Surgeon Fraud Causes

April 30, 2021 by in Blog

Healthcare providers, including surgeons, are required to comply with various federal and state healthcare laws. The Centers for Medicare and Medicaid Services (CMS) strictly scrutinize healthcare providers to make sure they are in compliance with federal law.  Surgeons especially are reviewed for program billings and reimbursement requests. It is important for surgeons and the hospitals or practice group they work for to carefully set up their billing practices to ensure that billing procedures are strictly in compliance with CMS’ reimbursement requirements and federal law.  Surgeons, and other healthcare providers, who fail to comply with federal healthcare law on billings and reimbursements, can face serious consequences under the federal False Claims Act (FCA) which may include large monetary penalties or even jail time for noncompliance.

If you are a surgeon or healthcare institution and have questions about whether your billings and reimbursement programs comply with federal law, contact an experienced Melbourne business lawyer at Lacey Lyons Rezanka today for a legal opinion and review of your billings practices.  Our attorneys have experience representing local hospitals and physician groups and we work diligently to meet our healthcare clients’ goals. Below are three common allegations made in surgeon fraud cases that you will want to be mindful of in order to prevent these allegations from being brought against you or your organization. 

Allegation #1: Billing Medicare for Services that Are Non-Reimbursable

One common allegation made against surgeons in healthcare fraud cases, particularly vascular surgeons, is submitting reimbursement requests to Medicare for services that are non-reimbursable.  Additionally, billing Medicare for services that are not performed by providers who are appropriately trained or credentialed, can also create compliance issues with federal healthcare laws.  Our Melbourne business lawyers with experience in healthcare law recommend that healthcare providers, especially surgeons, create a healthcare compliance program that ensures appropriate providers are providing treatments to patients.

Allegation #2: Falsifying Medical Records

Falsifying medical records should never happen.  However, unfortunately, some claims made under the FCA allege that physician examination results or other patient records were falsified or fabricated.  It is essential for surgeons, and other healthcare providers, to keep meticulous and accurate patient records in order to avoid potential allegations of falsifying notes to fraudulently substantiate evaluation and management visits, or other similar allegations.  Intentionally falsifying medical records in bad faith may yield penalties that are criminal in nature and could lead to jail time, in addition to large fines which sometimes may be in the millions of dollars.  Avoid these types of claims being made against your surgeons or healthcare institution by having your healthcare compliance program reviewed and evaluated by a Melbourne business lawyer with healthcare compliance experience. 

Allegation #3: Billing Patients for Services that are Not Medically Necessary

Medicare will only provide reimbursement coverage for medical services that are considered “medically necessary.”  Medicare may not cover procedures that are not necessary such as the performance of ultrasounds, or for vascular surgeries, a high ligation and saphenous vein stripping, among other treatments, unless they are medically necessary.  When submitting for reimbursement for these procedures from Medicare, healthcare providers must provide documentation of medical necessity.  Without this documentation, a request for reimbursement may be deemed fraudulent under the FCA. 

Have Questions About Healthcare Fraud and Abuse Laws? If So, Contact a Melbourne Business Lawyer to Discuss

Healthcare providers must comply with strict healthcare fraud and abuse laws.  Many of these laws are complex. If you are a healthcare provider and have questions about healthcare fraud and abuse laws, contact a Melbourne business lawyer at Lacey Lyons Rezanka today for a legal opinion.  Our legal team can answer questions you may have to ensure your healthcare program is in compliance with applicable law.

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