Healthcare fraud is a pervasive and serious crime that costs businesses and taxpayers billions of dollars each year. Virtually anyone can be charged with federal healthcare fraud, including physicians, patients, and anyone else who intentionally tries to deceive healthcare providers and insurance companies.
The U.S. government has numerous laws to investigate, charge, and convict someone of healthcare fraud, and the Federal Bureau of Investigation (FBI) is the primary agency that investigates alleged offenses. The FBI often partners with other federal, state, and local agencies, as well as insurance groups, and the U.S. Centers for Medicare & Medicaid Services (CMS) has created the Healthcare Fraud Prevention Partnership to combat fraud, abuse, and waste in the healthcare system.
Healthcare fraud can take many forms, and if you have been charged with the crime, or are under investigation, you need to understand the charges against you and the potential penalties you could face so you are informed and know what to expect. You should also consult with an experienced federal criminal defense attorney who can evaluate your situation and help you build the best defense strategy possible.
Types of Healthcare Fraud
The federal government defines healthcare fraud as knowingly and willfully trying to defraud any healthcare benefit program or obtaining money or property from a healthcare benefit program through false or fraudulent means
Medical providers and physicians can be charged with healthcare fraud for committing or trying to commit any of the following:
- Submitting several claims for the same service or billing for services a patient never received (double billing and phantom billing)
- Falsely inflating the expense of the treatment or billing for more expensive services than what the patient received (upcoding or overbilling)
- Submitting false claims to Medicaid or Medicare or private insurance companies
Patients and other individuals can also commit healthcare fraud by doing any of the following:
- Forging prescriptions
- Visiting several doctors to get multiple prescriptions for controlled substances (i.e., doctor shopping)
- Obtaining prescriptions for controlled substances so you can sell the drugs
- Using someone else's name or identity to get health benefits, insurance, or prescriptions
- Impersonating a doctor or other healthcare professional
- Submitting bogus claims to insurance companies
Whatever the case, the key element of the crime is that you intended to defraud. However, the law states that you don't need to have actual knowledge of this law or specific intent to commit a violation of it. In other words, you can be charged and prosecuted even if you weren't aware you were breaking a specific law.
Another criminal law involving healthcare fraud falls under the Anti-Kickback Statute. This law prohibits physicians from knowingly and willfully offering payment or services as “remuneration” to get patient referrals or business deals that involve any healthcare service or item paid by federal healthcare programs.
For instance, you can face federal charges if you bribe a Medicaid official to send more patients to your practice or to obtain drugs, supplies, or other material goods. Your payment could be in the form of cash, excessive compensation, or expensive gifts, such as a room at a luxury hotel or a gourmet meal.
The False Claims Act and Other Federal Healthcare Laws
One important area of federal law that deals with healthcare fraud is the False Claims Act. This law includes both civil and criminal penalties, and it makes it a crime to submit false or fraudulent claims to Medicare or Medicaid. Fines can be as much as three times the loss to the program plus another $11,000 per violation.
If you are a physician or healthcare provider, you could lose your license to practice or be excluded from participating in federal healthcare programs. Further, if convicted on criminal charges of healthcare fraud, you could receive up to five years in federal prison and fines up to $10,000.
Other important civil statutes that deal with healthcare fraud are:
- The Physician Self-Referral Law – Also known as the Stark Law, you cannot refer patients covered under Medicare or Medicaid to another practice that you own or one that has a close familial tie to you. For example, if you are a primary care physician, you cannot refer patients to your sister's imaging practice.
- The Exclusion Statute – You cannot participate in a federal healthcare program if you were convicted of Medicare or Medicaid fraud, patient abuse or neglect, or other felony healthcare violations, including felony-controlled substance violations.
The government can also use the Civil Monetary Penalties Law to pursue monetary penalties for a wide range of offenses, including all of those previously mentioned, as well as others. Penalties can range from $10,000 to $50,000 for each violation.
Additionally, you could face charges for conspiracy to commit healthcare fraud if you worked with others to perpetrate the offense.
Defenses for Federal Extortion
If you are a physician or healthcare professional, you have invested a lot of time and resources into your career. Even just being accused and investigated for healthcare fraud can irreparably damage your reputation and your practice, so you need to examine all your defense options to challenge any allegations or evidence and fight for your rights and future.
Since the prosecution must prove beyond a reasonable doubt that you intended to defraud and knowingly and willingly committed, or attempted to commit, the act, you may be able to show your actions were not intentional.
You may also have other defense options available, but you will need a complete and objective evaluation of your case from an attorney who has extensive knowledge of federal healthcare laws and experience defending against federal charges.
Get the Help You Need
Attorney Joseph D. Lento has in-depth knowledge of federal healthcare laws, and he has many years of experience defending clients in federal court. He can review your case and help you develop an effective defense against the charges. Call the Lento Law Firm at 888-535-3686 or fill out our contact form to request a confidential consultation.