A colleague of mine recently asked, “what does it take for a doc to get sent to prison?”
I had to confess: I really didn’t know. But as it turns out, there are several ways that could happen.
Let’s start with the differences between civil and criminal fraud. Civil and criminal fraud are essentially the same offense, but they undergo a different legal process. Much, if not most, of healthcare fraud is charged as a civil offense. There’s a range of reasons for this, but the main one is the burden of proof. In a criminal trial, the prosecution must prove guilt beyond a reasonable doubt. In civil cases, the burden of proof is lower – typically a “preponderance of the evidence” standard. This makes earning a conviction easier.
Criminal convictions expose defendants to the possibility of incarceration. This typically results in very aggressive defense. In contrast, civil convictions do not entail incarceration, but expose the defendant to a wide range of financial penalties not permitted in a criminal trial. Convictions of either type carry the risk of a corporate integrity agreement and exclusion from government programs. For these reasons, trials are less common than settlements.
In a settlement, defendants may avoid an explicit admission of wrongdoing while still being held liable for restitution and penalties. Examples of this in recent history include the kyphoplasty and cardiac device settlements.
The good thing is that criminal prosecutions for healthcare fraud are rare. There are several reasons for this. First, it’s hard to reliably identify a responsible executive and prove to a jury the executive’s guilt. Second, the dollar amounts are often so large and the possibility of penalties so great that civil charges result in better financial gains for the government. However, those in physician practices should take no comfort in the rarity of institutional criminal prosecutions.
The U.S. Department of Justice (DOJ) website has a “news” section that makes for fascinating reading.
Eliminating controlled drug charges and diversion, the schemes most popular for prosecution involve the following:
Let’s look at some examples to see what warrants “big time” in the “big house.”
These examples differ from institutional cases in that they have readily identifiable culpable individuals. They also allow us to start assessing risk for physicians.
Anytime a physician receives payment for something other than the delivery of care through a legal modality, it’s probably illegal.
EDITOR’S NOTE: This piece on RADV audits, written by Frank Cohen, was published on RACmonitor on Aug. 25, 2025. It’s being republished on ICD10monitor because
Clinical documentation integrity (CDI) professionals work in a variety of settings, and although I mostly focus on topics related to hospital inpatient billing, this week
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
