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Fraud and Abuse

1. Fraud is the intentional misrepresentation of facts with the intent to deceive.

2. Misrepresenting the duration of a mental health visit on a claim is one form of fraud. 

3. Fraud may also occur through concealment of a fact that should have been disclosed such as ownership in a company to which the practitioner refers.

4. Fraud also has three other components besides misrepresentation or concealment of the facts – (1) the professional must know that the statement is false, (2) the victim must rely on the false information, and (3) the victim must suffer harm as a consequence of the fraud.

5. Note that in mental health practice the victim may be the insurance company, the government (in the case of Medicare or Medicaid), or the patient.

6. The fiduciary relationship between a mental health provider and a patient makes any misleading statement more likely to qualify as fraudulent because the criteria about reliance on the information and subsequent injury to the patient (in terms of the therapeutic relationship) are almost always met.

7. Fraud may be litigated in either civil or criminal courts depending on the nature of the act and whether recompensation is sought.

8. Billing fraud is usually prosecuted criminally.

9. It is important to note that in criminal and fraud investigations, the psychiatric records of the provider generally are not privileged however the specifics may vary from state to state.