Protecting the Rights of Doctors Falsely Accused of Billing Fraud

Help for specialists facing false allegations from insurance companies

There are few professions nobler than medicine. Doctors and nurses often say that practicing medicine, much like teaching, is a calling. Sometimes that calling leads to challenges that other healthcare practitioners do not have to face, especially if you are a specialist in your field, or if you are the only practitioner of a certain kind of medicine in a large area. The last thing you deserve is a false allegation of fraud levied against you by an insurance company, TennCare or the Centers for Medicare & Medicaid Services.

At Banks and Jones in Knoxville, we fight hard on behalf of clients who stand to lose everything because of a false accusation of billing fraud. Our experience in the fields of personal injury and criminal defense gives us a unique perspective in cases like these, because we are familiar with how insurance companies operate, with the laws governing fraud in Tennessee and throughout the country, and with the medical field in general. If you are a doctor, a specialist or a healthcare worker who has been accused of billing for a certain code too often, we have the drive, the experience and the knowledge to help you fight back.

Understanding why you were audited

The first thing you need to understand is that the insurance companies are looking for fraud – even if you are doing everything you can to act honestly and ethically. Despite your best efforts, the insurance company will likely subject you to an audit if:

  • You bill under a specific code more often than other doctors in your area
  • You bill under a specific code more often than you bill under other codes
  • You bill under a G code that does not sufficiently reflect the same non-CMS code
  • You bill using outdated CPT intake codes
  • You bill for a medical necessity that the insurer deems unnecessary

Each of these examples may be chalked up to an innocent mistake – and private insurers, TennCare and CMS do not care. They are actively looking for errors to avoid reimbursing you. In some cases, these services may claim you are billing incorrectly when you are not, committing a form of fraud themselves.Even if you want to dispute the insurance company, you are contractually obligated to follow the guidelines set forth in the insurance company’s dispute resolution procedure. Many dispute resolution procedures state that the dispute is to be arbitrated instead of litigated at a location of the insurance company’s choosing, in hopes of deterring you from disputing the determination. In other words, the insurance companies have stacked the deck against you by contractually obligating you to travel for arbitration to a place that is most convenient for them.

The problems associated with billing under Obamacare

Dealing with Medicare and TennCare can cause additional problems as well, as the codes for each program are different. We know that G codes rarely match other ICD codes exactly, and that this poses an additional problem for doctors both green and experienced. This difference between codes may also lead an insurer to believe that you have falsely billed a procedure as medically necessary when it is not, because the standards of necessity differ for patients who use Medicare or TennCare as opposed to patients who do not.

This is why skilled, aggressive counsel is crucial to obtaining the reimbursement money you deserve. Banks and Jones does not back down in the face of giant insurers, and we refuse to allow those insurers to bully us into a panel of arbiters chosen exclusively by them. Our attorneys will travel to arbitrate a claim no matter the venue throughout Tennesse. We know that one false accusation can cost you tens if not hundreds of thousands of dollars, and we work tirelessly on your behalf to ensure that you do not lose everything you worked so hard to build. When you work with Banks and Jones, you can rest assured that a thorough and detailed strategy has been developed on your behalf, and that we do not rest until we prove that you deserve to be reimbursed.

Work with attorneys who understand the nuance of medical billing

At Banks and Jones, we offer comprehensive counsel for healthcare practitioners and professionals who are facing false accusations of fraudulent billing. If you need representation during arbitration proceedings, please call our Knoxville office at 865-546-2141 or contact us online to schedule a consultation.