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Chris T., JD
Chris T., JD, Attorney
Category: Legal
Satisfied Customers: 4829
Experience:  Experienced in both state and federal court.
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I am a trained acupuncturist. A few weeks ago, one of my patients

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I am a trained acupuncturist. A few weeks ago, one of my patients asked me to overcharge the insurance company about 600 usd for future visits. I made a mistake by following her request. Now she has reported me to the insurance company. What should I do? Should I write to the insurance company to explain the situation and to pay them back? Should I hire an attorney to deal with this situation? Thanks for your help. Meeya

TexLawyer :

First, you should hire an attorney.

Customer:

what kind of specialty

TexLawyer :

You must treat this situation carefully. There are two potential bad outcomes. First, you have committed the crime of health care fraud. While it may not be a large amount of money, it is still a crime.

TexLawyer :

Second, you don't want a ban from the insurance company.

Customer:

yes i have come to understand that

TexLawyer :

You should hire a health care attorney.

Customer:

where can i find a capable one?

TexLawyer :

If you need help finding one, you can use www.martindale.com or www.lawyers.com.

TexLawyer :

Both allow you to search be location and practice type.

TexLawyer :

Also, both have rating systems, so you know you are getting a good lawyer.

Customer:

such websites rarely explain who is better or worse in terms of dealing with such cases

Customer:

i see

Customer:

i wil hire an attorney monday

Customer:

here is what happened: i made the mistake in may. the patient informed me that she will need further treatments in june but the insurance company refuses to cover the expenses, hence she ask me to charge extra in may so that she can be treated in june.

Customer:

so i did what she asked, as the only case in my long practice

TexLawyer :

I understand. Your best argument is that you intended to perform the services and did not intend to defraud the insurance company.

Customer:

then i was informed that another patient covered by the same insurance company was asked to report all of her treatments since january.

Customer:

i have never performed such misconduct before

Customer:

and of course there is no fraud in the second case

TexLawyer :

While you will clearly be expected to pay the money back, and may even pay some penalties, it will likely avoid being banned. Also, they could put you on pre-approval before you receive future payments.

Customer:

therefore so far i still dont know why the insurance company is checking on the second patient, i am ONLY ASSUMING that it is related to the first patient, though i have no evidence that she did report me to the insurance

Customer:

i thought about writing to the insurance company to refund the extra treatments right away

Customer:

but am afraid of admitting my wrong-doing

Customer:

in so doing

TexLawyer :

I would not volunteer your wrong-doing until you are asked about it.

Customer:

i agree

Customer:

i have zero intention of keep any extra payments.

Customer:

so do you think that i should wait until the investigation letter comes to me to hire a lawyer or should i hire a lawyer now?

TexLawyer :

You should wait until you receive the investigation letter.

Customer:

as i still am not certain why the insurance company is doing the investigation on the second patient, i think that i should just stay put and take no action

TexLawyer :

Yes, just wait for now.

Customer:

but in the meantime the wrongdoing eats my mind daily

Customer:

the anxiety about the second reflects upon my own sense of the ethical situation

Customer:

the second patient and the first patient

Customer:

i meant

Customer:

so here are the situations: 1. i should take no action until the investigation letters come

Customer:

2. if the letters come i should hire a lawyer

Customer:

my next question is: should i speak to any of these two patients?

Customer:

i am eager to resolve this, it seems that i should take no action until then

TexLawyer :

You've got it. No, you should not speak to the patients. You don't want anything construed as if you are tampering with "witnesses."

Customer:

next question: what would be the worst outcome?

Customer:

fine? imprisonment? suspension of my license?

TexLawyer :

In theory, criminal prosecution, but that is extremely unlikely.

Customer:

the amount involved is about 760 usd

Customer:

what about fine and suspension of licence?

TexLawyer :

The second worst outcome would be some action on your license. Again, that is very unlikely.

Customer:

then fine and financial penalty

Customer:

which i will happily accept

Customer:

it was my fault anyway

TexLawyer :

Third, would be a sanction by the insurance company. That is the most likely, but you should be prepared to accept some penalty to avoid a ban from the insurer.

Customer:

what is the most likely?

Customer:

great

Customer:

in your best judgment how much legal fee should this case incur? just a range would do.

Customer:

i understand things vary case by case

TexLawyer :

$1500-5000.

Customer:

great

TexLawyer :

That is largely a guess, but that's my best estimate.

Customer:

why does the insurance company would check on the second patient?

Customer:

is it really related to the first patient?

Customer:

i understand my own conscience is making the connection, but what is your professional judgment?

TexLawyer :

In all honesty, it is very difficult to say.

Customer:

i see

Customer:

when the insurance company checks on a patient's record for the last six months, does it imply a suspicion of the care provider's credibility?

TexLawyer :

It could be for a number of reasons, possibly related to patient care issues, or an investigation into another provider.

Customer:

r an investigation into another provider.

Customer:

do you mean another patient?

TexLawyer :

Another patient or provider. Sometimes the treatment history of a patient can shed light on another provider.

TexLawyer :

Again, it is very hard to say.

Customer:

conclusion:

Customer:

1. i should not return the payment to the insurance company

Customer:

2. i should not contact the patient/s

Customer:

3. i should wait for the insurance company to contact me

Customer:

4. when the insurance company contacts me i should immediately hire the most effective attorney

Customer:

5. i should expect to pay a refund and some penalty/fine and be possibly put on a sanction

Customer:

6. i should expect to pay a 1500 to 5000 usd legal fee to cover the case

Customer:

did i get all your points?

TexLawyer :

That's correct.

Customer:

anything else i should know?

Customer:

i am prepared to take all my responsibilities

TexLawyer :

Not that I can think of. If you get more information and have questions in the future, you can direct them to me by posting a question with "this question is for TexLawyer" in the title.

TexLawyer :

If I can't do anything else for you tonight, please remember to "rate" my answer.

Customer:

thanks, XXXXX XXXXX

Customer:

i am yet to learn more about this website

Customer:

so when i come back how should i find you

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