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Criminal Evidence in Health Care Billing Fraud Cases

By Laura A. Perkovic

Health care billing fraud cases involve a great deal of data and documentation which can, by itself, tell a convincing story to a jury. Understanding the kind of evidence used in health care billing fraud cases will help attorneys and clients assess the strengths and weaknesses of their case.

Billing Claims Data

Billing claims data is key evidence and the heart of a health care fraud case. When a provider submits a claim, and the claim is processed and paid, this information is retained in a database by Medicare, Medicaid, their contractors, or private insurance companies. The claims data shows information such as rendering provider, date of service, billing code, amount billed, date billed, whether the claims were submitted electronically or on paper, and claim status (e.g. paid, denied, adjusted). The data can typically be produced in Excel spreadsheet format.

The claims data can be examined in a number of ways. It can be isolated to show all services billed by a particular rendering provider; or isolated to show claims billed for a particular patient/beneficiary by all providers. This raw data can show rather convincing evidence of fraud in some cases.

For example, suppose an allegation involves Dentist billing for services that were not actually provided to her patients. The Dentist’s claims data will show names of all Dentist’s patients over a selected period of time. Additionally, claims data for each of the patients can be obtained, and will show whether other health care providers billed for services on the same day as Dentist. Suppose the data shows Dentist billing for a root canal on the same day a local hospital billed for a surgery, followed by a lengthy hospital stay for patient Jane Doe. This raw data can provide rather convincing evidence of fraudulent billing on the part of Dentist (when there is a pattern of this sort of activity rather than an isolated event). Obviously, there will be more to the story, but this sort of “data mining” is used frequently by state Medicaid programs and audit contractors, and can play a valuable part in state and federal health care fraud detection and investigation.

Patient Charts

Patient records/charts are another source of evidence for health care fraud investigations. According to each provider agreement (the contract signed between the provider and the payor), as well as various regulations, providers must document services at the time they are rendered, and retain records for a certain number of years.

The charts/records will show a number of things valuable as evidence in a health care fraud investigation:

  • Whether documentation supports reimbursement for a particular code (e.g. encounter time, or complexity to justify level of care);
  • Complete absence of documentation;
  • Alteration or records;
  • Rendering provider (e.g. records show a non-physician midlevel rendering service, but billing shows the MD or DO as rendering service);
  • Medical necessity or lack thereof for narcotics prescriptions, testing, etc.

Provider Business Records

A number of non-patient business records can provide simple yet valuable evidence in health care fraud cases.

  • Schedules will show which patients were assigned to which provider, vacation dates, and check-in/check-out times;
  • Payroll will show hours and days worked as well as compensation;
  • Expenses such as vendor payments will show equipment and supplies purchased by the provider;

This evidence will either be consistent or inconsistent with the volume of work and revenue shown by the provider billing data.

Personal Records

Certain personal records can provide evidence of fraud, when certain personal activities took place on those times and dates when professional services were supposed to have occurred. For example:

  • Credit/debit card transactions could show a provider on vacation;
  • Multiple employer payroll records could show an employee claiming to be in two places at the same time.

Conclusion

Defending a health care fraud case requires knowledge of the health care industry, proficiency in criminal law, and subject-related experience. As a former health care fraud prosecutor, Attorney Laura Perkovic she has extensive experience in health care-related crimes and now focuses her practice on helping doctors, nurses and other health care professionals in individual and corporate prosecutions, government investigations, and navigating the minefield of federal and state regulations. Chapman Law Group is a firm focused exclusively on the needs of health care professionals, and handles cases in many courts throughout the nation. It is wise to consult with an experienced legal team as soon as government investigators make contact with you or your business, in order to understand your rights, obligations, and exposure.