What should I do if I suspect my doctor of fraud?

What To Do If You Suspect Your Doctor of Fraud

If you have a feeling your doctor is doing something illegal or unethical, it can be scary. You put your trust in this person to care for your health, so finding out they may be dishonest can feel like a betrayal.

But you don’t have to keep quiet if you suspect your doctor of fraud. There are steps you can take to report them and make sure they are held accountable.

Trust Your Instincts

First, don’t ignore your gut feeling. If something seems off with the way your doctor bills your insurance, prescribes medications, or recommends unnecessary procedures, pay attention. Some signs your doctor may be committing fraud include:

• Billing for services they didn’t perform
• Billing multiple insurers for the same procedures
• Prescribing brand-name drugs when generics are available
• Ordering excessive or unneeded tests

Of course there could be valid reasons for some of these behaviors. But if you have a nagging feeling something shady is going on, it’s smart to investigate further.

Do Your Research

Before making any fraud accusations, make sure you have evidence to back up your claims. Do some digging like:

• Review your medical bills and EOBs from your insurance to verify services billed
• Research average costs for procedures you had to see if you were overcharged
• Look into your doctor’s credentials and disciplinary history
• See if others have filed complaints about similar misconduct

If you confirm questionable billing practices or excessive procedures that aren’t medically warranted, you’ll have documentation to demonstrate why you suspect fraud.

Report Your Doctor

Once you’ve gathered information about potential wrongdoing, it’s time to file a report. You can notify these agencies about your doctor:

• U.S. Department of Health and Human Services Office for Civil Rights – handles HIPAA violations related to privacy of medical information
• Medicare – investigates Medicare fraud
• Your state medical board – regulates doctor licensing and investigates misconduct
• Your state attorney general’s office – prosecutes various consumer fraud crimes

When filing your complaint, present the details about your suspicions clearly along with any proof. Records like visit summaries, test results, billing statements, and payment receipts can help support your allegations.

What Happens Next

After reporting doctor fraud, investigators from agencies like the FBI, IRS, or HHS Office of Inspector General may get involved. They’ll examine factors like:

• Medical necessity of services
• Billing irregularities and overpayments
• Suspicious prescribing patterns
• Procedures billed that weren’t performed

Your doctor will have a chance to respond to the fraud claim. If enough evidence demonstrates wrongdoing, they may face:

• Fines and repayment demands
• Loss of medical license
• Exclusion from state/federal healthcare programs
• Criminal charges like wire fraud, identity theft, or kickback violations

As the person who reported your doctor, you likely won’t be updated about details of the investigation. But you can rest assured the proper authorities will discipline your doctor appropriately if they discover unlawful activity.

Consider Finding a New Doctor

Even if agencies are still investigating your doctor, you may want to look for a new provider. Continuing care from someone you suspect of fraud can feel really uncomfortable. It may damage the honesty and trust that are essential in a good doctor-patient relationship.

Shop around for an ethical doctor you feel you can count on to offer first-rate care without overbilling insurance or recommending needless procedures. Having confidence in your provider’s integrity will lead to better health outcomes.

Suspecting your own doctor of fraud is an awful position to be in. But coming forward about your concerns can stop ongoing misconduct that wastes healthcare dollars and risks patient wellbeing. Pay attention to warning signs, thoroughly document issues, and report shady behavior to protect yourself and prevent future victims.

Citations

U.S. Department of Health and Human Services Office for Civil Rights: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Medicare: https://www.medicare.gov/MedicareComplaintForm/home.aspx