An article published online in The Atlantic earlier this year discussed Attorney General Loretta Lynch’s statement that “243 people were arrested and charged with stealing $712 million from Medicare,” which she claimed was “the largest criminal healthcare fraud takedown in the history of the Department of Justice.” The article went on to cite statistics from NPR and ProPublica, as well as other sources, of Medicare fraud being performed by doctors, nurses and other healthcare professionals over the years through inappropriate billing. The point they were trying to make is that medical professionals commit more healthcare fraud than people.

But is it really true? What the article does not discuss is how often doctors are accused of committing billing fraud, when in actuality the system is so convoluted that much of this “fraud” is just a series of genuine mistakes – or what are claimed as mistakes, even when no mistake has been made.

How the system works

TennCare, CMS, private insurers – these companies are actively looking for cases of “fraud” by doctors, nurses, pharmacists and healthcare professionals. They do not take any extenuating circumstances into account. For example: let us say you serve a more rural area of Tennessee without a nearby hospital. The chances are good that you regularly perform tests or procedures that patients would have gone to a hospital to have done. When TennCare sees that you have billed for such procedures, they do not investigate why you are billing for them; they automatically assume you are trying to “game the system.” They claim fraud and refuse to pay for those procedures. Moreover, they may be able – under the law – to demand back payment for anything you have ever billed for, because if you are committing fraud now, who is to say you did not do it then?

You may be accused of billing fraud for simply doing your job to the best of your ability as well. Using a more specified code for one procedure than for another can raise a red flag; so can billing for a procedure that is a medical necessity in real life, but not in the eyes of the insurer. Add in the discrepancies between Medicare billing and TennCare billing, top it off with the new ICD codes that went into effect this year, and you have a recipe for disaster.

These are incredibly complex cases which require the help of an attorney who understands not only the rules regarding billing codes, but who is willing to travel throughout Tennessee for the arbitration process. At Banks & Jones in Knoxville, our lawyers are able and willing to do just that. If you are a doctor, a nurse or another healthcare professional who has been wrongfully accused of billing fraud, we know what it takes to help you. Please contact us to reserve a consultation at our Knoxville office.