Can a physician’s honest mistake be considered health care fraud?

On Behalf of | Jun 14, 2023 | Health Insurance & Medicare Fraud |

With so many residents of Tennessee burdened by medical debt, the issue of health care fraud is a serious one. Health care fraud is a federal crime, and physicians convicted of health care fraud can face steep fines, restitution and possibly incarceration.

Still, sometimes a physician might commit an act of health care fraud by mistake. If so, will they still be held criminally responsible for the inadvertent act of fraud?

Examples of health care fraud

First, it is important to know what health care fraud looks like. Some examples of health care fraud include double billing a patient for the same service, seeking payment for care never provided, submitting several bills to an insurer for the same service or billing a patient for a pricier service than what was provided.

Fraud or mistake

The difference between health care fraud and a mistake can boil down to intent. A fraudulent act is an act that is intentionally committed to deceive or mislead the target of the fraud.

To commit fraud, the actor must know that they are stating something untrue or have no regard for whether a fact they stated is true or false. This untruth must result in the target of the fraud relying on the untrue statement to their detriment.

A mistake requires no criminal intent, and the physician truly believed they were correct in what they were stating. However, a mistake can turn into health care fraud if the physician discovers the mistake but fails to remedy it and continues to seek payment despite knowing the amount asked for was wrong.

Intentional or negligent misrepresentations might be considered acts of health care fraud, while honest mistakes made in good faith might not. Still, a mistake can turn into a criminal act if it is not remedied to the detriment of the patient or insurer.

Physicians must be very careful when billing patients and insurers to avoid making mistakes that might be considered health care fraud.