Spot and Avoid Health Insurance Fraud

Health insurance fraud is a serious accusation when someone deceives their insurance company. This happens when people intentionally lie to their health insurance company to trick them.

Understanding the intention behind the actions helps us determine if the accusation is valid. If there was no intent to deceive, the accusation may not be true. It would be unfair to penalize someone if they didn’t mean to deceive the insurer.

Overview of Health Insurance Fraud in Texas

Health insurance fraud is when people lie to make the company pay for things they shouldn’t. In Texas, there’s a rule called Texas Penal Code Section 35.02 that says you can’t do this on purpose. It’s not okay to trick or cheat with insurance claims or health plans.

Types of Health Insurance Fraud

Prescription Fraud

Fake Prescription: Making or using fake prescriptions.

Misuse: Using medical records for the wrong reasons, like selling medicine.

Doctor Hopping: Going to lots of doctors to get too many prescriptions.

Fraud Done by Patients and Others 

Stealing Identity: Using someone else’s insurance or letting someone use yours

Fake Ads: Tricking people into giving their health insurance information for fake services or to steal their identity

Pretending to Be a Doctor: Doing or billing for health stuff without a license

Fraud Done by Medical Professionals

Phantom billing is asking for money for things that didn’t happen.

Upcoding: Asking for payment for something fancier than what actually happened.

Charging Twice: Sending many bills for one thing.

Unbundling: Sending many bills for just one thing.

The Health Insurance Fraud Law in Texas

Just like the rules everywhere, Texas has its own laws about life insurance fraud and abuse that companies need to follow. These laws cover:

Texas Patient Solicitation Act (Texas Penal Code 102.001): The Anti-Kickback Act manages how doctors refer patients to one another. If someone commits insurance fraud, they could face criminal charges, even for small gains. It’s crucial to realize that the person should have been aware that breaking the law went against the rules. In other words, they knew the law didn’t allow their actions.

Restriction on Unauthorized Entities: Doctors can’t work for people or businesses that aren’t officially allowed to do medical work.

The Texas False Claims Act (Texas Penal Code 165.156) holds people accountable if they fool the government into paying for things that aren’t real. The law is similar to the False Claims Act. However, it has harsher punishments if the false claims harm older people, disabled individuals, or children.

The Texas Medicaid Fraud Prevention Act (Texas Human Resource Code Chapter 36) prevents dishonesty in the Texas Medicaid program. People can’t create fake papers or claims to get money from the state Medicaid program.

Wrong Billing Practice (Texas Penal Code 32.47): Punish doctors who bill wrongly. Sending false bills can lead to big trouble and license loss.

Both the United States and the entire nation actively dedicate themselves to stopping healthcare fraud. If you’re worried about fraud, don’t hesitate to report fraud activities to law enforcement. They can help you understand your situation and guide you on what to do next.

Consequences of Health Insurance Fraud in Texas

In Texas, the punishment for health care fraud varies based on the money involved in the false claim or dishonest benefits.

Class A misdemeanor: You could be imprisoned for a year and fined $4,000 if you got benefits valued under $2,500.

Third-degree felony: For benefits amounting to $2,500 to $30,000, this could result in a prison sentence of 2 to 10 years and a fine of up to $10,000.

Second-degree felony: If benefits range from $30,000 to $150,000, consequences include 2 to 20 years in prison and a fine of up to $10,000.

First-degree felony: For benefits totaling $150,000 or more, the penalty might involve 5 to 99 years in prison and a fine of up to $10,000.

These are just a few of the punishments for health insurance fraud. Along with big fines and trouble with the law, people who commit fraud might lose their license to work in healthcare.

Medicare or Medicaid may bar companies caught committing fraud with medicines or medical devices from participating later on.

Protect yourself from Health Insurance Fraud

• Protect your health insurance information like a credit card. Don’t share it; be careful at the doctor’s or pharmacy.
• Watch out for scams offering “free” medical services; they might misuse your information.
• After treatment, review your bill closely. Ask your doctor about unclear services. Tell your state insurance company if you see any problems.
• Keep your insurance card safe. Report waived payments without reason.
• Be careful when sharing your insurance number with marketers.
• Don’t sign blank insurance forms.
• Check your benefits statement for accuracy. If something’s wrong, contact your insurance.

Arrested? Don’t Plea, Call Me!

When facing accusations of insurance fraud schemes, insurance companies might choose not to offer coverage in the future and could cancel the current policy. Still, insurance companies might play down these effects to reject real claims. When accused of false claims, a strong defense could lead to reduced charges or dismissal.

An experienced lawyer can put together a strong argument by looking at things like not meaning to do something wrong, getting mixed up with someone else, having a good reason, feeling pressured, or having your rights ignored. Our team at Texas Criminal Defense is here to help you get the best result for your legitimate claims. We’re a capable and committed team here to support you. We’ll put in the effort to make sure things go well for you in this situation.