Florida's Fight Against Medical Insurance Fraud and its Unintended Victims

 It's estimated that Medicare, Medicaid and private medical insurance fraud costs the $2 trillion healthcare industry in excess of $100 billion dollars per year.  In the current economic environment, "controlling rising healthcare costs" and "enforcing fiscal discipline" are two talking points that appear in every politician's public agenda. Often you'll hear politicians and the news media employ the word "crisis" to justify a call to action.

There's no doubt that Medicare, Medicaid and private insurance fraud are significant problems in a state like Florida. However, as is the case whenever any issue becomes topical, the reaction can sometimes be so zealous that the need for agencies to report impressive arrest numbers begins to take priority over the responsible prosecution of the crimes. Doctors and medical personnel who may have only made billing errors or unwittingly associated themselves with unscrupulous employees or patients often find themselves to be the subject of a Medicare, Medicaid or private insurance fraud investigation. A resulting criminal charge could result in the loss of licensing, irreparable damage to one's professional reputation, the payment of fines and even jail time.

Here are a few examples of the types of activities that agencies like the Florida Department of Insurance Fraud typically investigate, but can often be confused with legitimate medical billing processes:

Fraudulent Billing – This is when a healthcare provider bills an insurer for a service that the insured patient never received. While this could be the result of an illegal act, it could also have occurred because of a clerical error. Or it could also be the act of a sole perpetrator employed by an innocent third party.

Medical Equipment Billing – This occurs when a healthcare provider bills an insurance company for some equipment that the insured party doesn't need or never receives. It works in the same way as fraudulent billing, and the risks of a prosecutor mis-targeting an innocent person are similar.

Coding Error – While most coding errors are unintentional, occasionally a person working in the employ of a healthcare provider intentionally changes the code to that of a more expensive service. This is also referred to as upcoding. The insurer then pays a higher amount than is actually due. It's unlikely that prosecutors will be able to make a case on a single reported incident, but a few reported errors could bring a doctor or healthcare provider under investigation despite their lack of knowledge or intent.

Unbundling/Exploding – These terms refer to the practice of parcelling out a series of tests to increase the overall costs to insurers. Naturally, this could be the result of an unethical medical practice, or it could be that the tests were separated by necessity.

The important thing to recognize is that the United States and State of Florida is aggressively prosecuting all types of fraud. The independent watchdog group Coalition Against Insurance Fraud (CAIF) 2007-2008 statistics, Florida ranks in the top four (4) among all states’ fraud divisions and bureaus in key measurements of success:

2nd in the number of arrests
3rd in the number of cases presented for prosecution
4th in the number of referrals

If you are a doctor or medical professional in Florida, and Federal and State criminal investigators are investigating you for private medical insurance fraud, Medicare fraud or Medicaid fraud, contact an attorney who specializes in this area of the law. Prosecutorial mistakes happen frequently, and you shouldn't let one negatively impact your business or your reputation.


Charles B. Lembcke has been recognized as one of the Best Lawyers in America in the area of white collar criminal defense.

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