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What is Fraud Investigation?


Fraud investigation occurs when a state or Federal agency suspects a medical practice of making fraudulent mistakes in their Medicare and Medicaid billing. A fraud investigator can be hired by a private company, the FBI, or the IRS to investigate possible fraud in your practice. Fraudulent claims and patterns of erroneous medical coding are likely to catch the attention of fraud investigators. Common scams that can result in a fraud investigation include:

  • Billing for services not rendered
  • Purposefully using incorrect codes to increase Medicare and Medicaid payouts, and
  • Submitting fraudulent claims

Healthcare professionals convicted of fraud can be fined hundreds of thousands of dollars, and in some cases millions. Jail time is also a common result of a fraud investigation that is brought to court. In order to avoid a fraudulent investigation in your practice, you should:

  • Follow Medicare guidelines whenever using management or evaluation codes
  • Ensure diagnostic codes are as specific as possible
  • Provide ongoing coding education for staff and physicians in your practice
  • Establish a compliance program, and
  • Review any and all fraud-related complaints as quickly as possible

One mistake won’t land you in prison, but a systematic failure to follow Medicare’s guidelines may spark the interest of a fraud investigator. Be sure you have a thorough understanding of the guidelines that must be followed before you open your practice.

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Author: DBN

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