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Medical Billing Expert Witness – Physician Billing Fraud case explained

Medical Billing Expert Witness – Physician Billing Fraud case explained

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Med League Support Services provides medical billing expert witness to review medical billing fraud cases. According to The Washington Post, former Virginia physician Leonard Rosen, MD was sentenced for his role in a $1.8 million fraud scheme against payers and patients.  Dr. Rosen was alleged to prescribing medically unnecessary and expensive medication to patients to receive kickbacks and also billed some in-network patients as an out-of-network provider and made $100K in bribes.  Dr. Rosen was part of this large fraud scheme where physician prescribes expensive drugs through network of pharmacists who then pay bribes to fill the order. Court records claim that the scheme was first started by two other physicians, only one of whom has been charged with a crime.

Often times, these types of fraud cases will require expertise of a medical billing expert witness to identify and review types of bills and transactions to justify the fraudulent activity performed.

Understanding the three most common forms of medical billing fraud and how Medical Billing Expert Witness can help

Upcoding Fraud:

Upcoding is a kind of medical billing fraud that occurs when a provider sends a bill to Medicare or another payor for a more expensive service than the one actually performed. For example, the provider might:

  • exaggerate the time the procedure took to perform
  • misstate the equipment involved in the procedure
  • lie about the staff involved in performing the procedure
  • bill for individual therapy when group therapy was actually provided
  • simply make up that a procedure happened
  • perform (and bill for) procedures that patients simply do not need in violation of “medical necessity” rules

Upcoding also occurs with risk adjustment fraud committed under Medicare Part C, when a Medicare Advantage patient’s diagnostic data is exaggerated in order to draw additional risk adjustment payments from Medicare.

Unbundling Fraud: 

Unbundling is a fraudulent billing scheme accomplished by billing several different procedure codes for a group of procedures, even though the group should properly be billed under a single all-encompassing code. The sum of reimbursements for each code paid separately is higher than the reimbursement for the comprehensive code, causing an overpayment. For example, a physician might order a panel of blood tests for a particular patient. The laboratory receiving the order commits fraud if, instead of billing for the panel, it attempts to increase its income by billing separately for each test conducted.

Billing for Services Not Provided

The Government will only pay for medical services that are actually performed or for equipment that is actually delivered. It can be a violation of the False Claims Act to bill the Government for healthcare services, supplies or equipment that were not performed or delivered. While sometimes bills are submitted for completely fictional services, medical billing fraud also happens when, for example, a diagnostic testing lab submits a bill claiming it has performed both a two dimensional CAT scan and a sophisticated 3D scan and analysis, when, in fact, only the 2D scan was performed.  They are billing for service that was not actually provided.



As a result of his fraudulent act, Dr. Rosen’s medical license has been revoked and he’s being sentenced to two years of probation with six months of at home confinement according to the post.

Med League provides medical billing expert services to review medical billing fraud cases.  Contact us for a free case consultation on your next medical billing fraud case.

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