All licensed professionals are subject to certain laws and rules that apply to their professions. The Texas Medical Board (TMB) is the state agency that licenses, regulates, and monitors physicians and other professionals for compliance with the laws and rules that govern them. Insurance fraud is an increasingly common allegation that medical practices may face before the TMB and other regulatory agencies.
Violations of rules and laws related to your profession, including insurance fraud, can lead to disciplinary complaints and sanctions that can adversely affect your career. In severe cases, you could even face a license suspension or revocation, which affects your ability to keep your job and support yourself. A Texas medical license defense lawyer can represent your interests before the TMB and put you in the best position to handle the disciplinary proceedings against you.
How Insurance Fraud Can Damage Your Practice and Your License
You and your medical practice must follow countless federal and state laws and regulations to accept private insurance, Medicare, and Medicaid from your patients. If you run afoul of any of those laws, you could face accusations of insurance fraud, which are extremely serious and have the potential to end your career. Not only could you face state and federal criminal charges, but you could face civil penalties, as well as disciplinary action against your license by the TMB. For these reasons, understanding and taking steps to always comply with insurance laws and rules is critical.
Common Types of Insurance Fraud
Many allegations of insurance fraud stem from improper billing for patient services. Various rules exist about how to document services that doctors have provided for patients, how to justify the medical necessity of those services, and how to properly bill for those services. However, in some cases, doctors may fraudulently bill private insurance companies, Medicare, or Medicaid, for unnecessary medical treatment, or treatment that they never provided. In other cases, doctors may create fictitious patients or use false identities to create patients to perform false billings.
Doctors also may engage in excessive billing by ordering unwarranted amounts of diagnostic tests or exploratory procedures. They may bill for more expensive medical procedures instead of the less expensive procedures that they performed. Another common fraudulent scheme is to waive patient co-payments or deductibles to overbill the insurance company.
Another form of insurance fraud occurs when doctors accept kickbacks, bribes, or other forms of financial compensation for patient referrals. Doctors may also dishonestly or inappropriately prescribe certain drugs so that they profit from the sale.
Tips to Avoid Allegations of Healthcare Fraud
As federal and state governments increasingly crack down on insurance fraud, and Medicaid and Medicare fraud, in particular, doctors and medical practice can take some common-sense steps to minimize the potential for healthcare fraud in their offices. Following these guidelines also may help decrease the chances of the kinds of red flags that could lead to extensive audits and allegations of fraud against them. Doctors and their staff always should follow these practices:
- Never accept payment for patient referrals;
- Never perform procedures that insurance companies normally would not authorize or cover;
- Do not falsify medical records, misdiagnose patients, or misrepresent the services provided;
- Bill only for medical services performed;
- Review every insurance claim thoroughly for accuracy before submission;
- Ensure that an experienced claims professional handles all insurance billing and coding, and that a second professional acts as a safeguard so that no one person is solely responsible for insurance claims;
- Bill the costs of procedures and services correctly; and
- Perform only medically necessary treatments and procedures.
Insurance Fraud Audits
No matter how careful you are to avoid insurance fraud, audits by insurance companies and the federal government concerning Medicare and Medicaid have increased in recent years as concerns about insurance fraud have grown. These audits may uncover inconsistencies and a lack of documentation that leads auditors to conclude that fraud must have occurred, even if that is not the case. By dealing with these allegations head-on, you may be able to handle false fraud allegations before they lead to greater problems. Taking a proactive approach to remedy mistakes in documentation from the outset of an audit may be the best way to potentially avoid a much more disastrous situation.
If you are unable to deal with false fraud allegations during an audit, then a criminal investigation and potential charges are likely to ensue. These charges can be extremely difficult to overcome, particularly if you don’t have the documentation to back up your claims. Along with criminal charges will come an investigation by the TMB, which likely will lead to consequences for your ability to practice medicine, as well.
The TMB and Insurance Fraud Allegations
Allegations of insurance fraud are likely sufficient to trigger a disciplinary investigation by the TMB, even if you are not yet been convicted of insurance fraud. Tex. Occ. Code § 164.052 states that physicians also commit a prohibited practice if they commit unprofessional or dishonorable conduct that is likely to deceive, defraud, or injure the public. Under Tex. Occ. Code § 164.053, “unprofessional or dishonorable conduct” is any act that violates state or federal law if connected with the practice of medicine. This section also states that “a complaint, indictment, or conviction of a violation of law is not necessary” to enforce a violation of this type of unprofessional or dishonorable conduct.
22 Tex. Admin. Code § 190.8(2)(J) also states that: “providing medically unnecessary services to a patient or a third-party payer that the licensee knew or should have known was improper” is an actionable violation for physicians that could lead to disciplinary action. This section also states that “[i]mproper” means the billing statement is false, fraudulent, misrepresents services provided, or otherwise does not meet professional standards.” Therefore, insurance fraud as a basis for disciplinary action.
Possible Sanctions for Insurance Fraud in TMB Disciplinary Cases
You can face serious sanctions resulting from TMB disciplinary proceedings that likely will directly affect your ability to continue practicing medicine. These possible sanctions include the following:
- Revocation or suspension of your license;
- Placement on probation during a license suspension;
- Public or private reprimand;
- Placement of restrictions or limitations on your license; and
- Assessment of an administrative penalty.
Furthermore, any felony convictions that result from insurance fraud also will result in the TMB revoking your medical license.
Bertolino LLP: Ready to Defend Your Interests Before the TMB
Retaining an experienced Texas medical license defense attorney to represent you before the TMB is in your best interest. We are here to protect our interests throughout every stage of your disciplinary proceedings. Contact the lawyers of Bertolino, LLP today by calling (512) 515-9518 or visiting us online.
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