What Is Medical/Health Care Fraud?
Medical/health care fraud involves an individual or a company defrauding private insurance companies, Medicare, or Medicaid. Basically, health care fraud occurs when a provider claims something that isn't true relating to the patient's diagnosis or the treatment provided so that the provider can bill higher charges and increase their own profit.
Patients can also be charged with medical/health care fraud for deceiving their health care or insurance provider for their own benefit.
There are several ways that medical/health care fraud can be perpetrated, including the following:
- The provider might diagnose a patient with a condition that the patient does not actually have
- The provider might falsify charges in billing reports
- The provider might claim inaccurate treatment plans or misstate medical records
- The provider might bill for treatment that is not medically necessary
- The provider might try to get a kickback in exchange for services
- The provider might bill for procedures that were not performed
- A patient might fake a condition in order to get medication and sell the medication on the street
- A patient might forge a prescription
- A patient might falsify their information in order to obtain insurance coverage
What Laws Govern Federal Medical/Health Care Fraud?
There are a variety of federal laws that apply to medical/health care fraud.
- The Federal False Claims Act (FCA) places civil and criminal penalties on those who make fraudulent claims to government healthcare programs like Medicare and Medicaid.
- The Anti-Kickback Statute (AKS) prohibits health care providers from accepting any sort of payment in exchange for referrals.
- The Stark Law prohibits health care providers from referring patients to a facility where the provider has a financial interest.
- The Criminal Health Care Fraud Statute prohibits providers from conspiring in a scheme to defraud a healthcare benefit program.
- The Exclusion Statute ensures that people or groups who commit certain offenses cannot participate in any government healthcare program. These offenses include:
- Medicare or Medicaid fraud
- Felony theft or financial misconduct
- Felony controlled substance violations
- Patient abuse
- The Civil Monetary Penalties Law (CMPL) provides penalties for making false claims to Medicare or Medicaid, submitting a claim for something that has not been provided, or accepting kickbacks.
What Will Happen if I Am Convicted of Federal Medical/Health Care Fraud?
Healthcare fraud is not a victimless crime; it increases costs for insurers, and those costs are passed on to patients in the form of increased deductibles and premiums. As a result, there are serious criminal repercussions for federal medical/healthcare fraud.
Penalties for medical/health care fraud can include the following:
- Paying fines
- Paying restitution
- Prison sentences
- Exclusion from participating in Medicare or Medicaid programs
- Loss of medical license
- Loss of DEA registration
- Seizure of assets
The Federal Criminal Process
Before they can charge you with a federal crime, federal prosecutors have to get a grand jury indictment against you in order to prosecute. Then they can issue a warrant, and you can be arrested. After being arrested, you will have an initial appearance in court where you are told what crimes you are being charged with, and you can plead guilty or not guilty. Next, there will be a preliminary hearing, at which time the judge will decide whether there is enough evidence to continue to prosecute you. The prosecutor will present their evidence, and the judge will decide if that evidence is sufficient to continue the process. If so, the next step is called discovery. Discovery involves the prosecution and the defense exchanging all of their evidence. After discovery, you may be offered a plea bargain. This is an opportunity to accept a lighter sentence and avoid going to trial. If you don't accept a plea bargain, then your case will go to trial, where a jury will hear your case. If you are convicted, you will enter the sentencing phase, which does not happen immediately. A probation officer will interview you and prepare a report, and finally, the judge will sentence you based on all of that information.
How Can I Defend Myself Against Federal Medical/Health Care Fraud Accusations?
The healthcare industry is complex and heavily regulated, so the defenses that are applicable to your case vary based on your circumstances. The most common defense against medical/health care fraud is lack of intent. You cannot be punished for making an honest mistake. The prosecution has to prove that you intentionally committed fraud.
Where Will My Case Be Heard?
Federal Medical/Health Care fraud cases are brought in a United States District Court. If the crime occurred in New Jersey, the charges will be brought in the United States District Court, District of New Jersey.
Why You Need an Experienced Attorney to Help
Federal Medical/Health Care fraud charges are serious charges that can result in major fines and years in prison. Do not try to fight these charges without an expert federal criminal defense attorney. An experienced federal criminal defense attorney will evaluate the case and help you figure out the best defense for your circumstances. You may have the option to consider a plea bargain to avoid a harsh sentence. An experienced criminal defense attorney will guide you through that process.
The Lento Law Firm Is Your Best Choice
The federal criminal defense process is complicated, but Attorney Joseph D. Lento has many years of experience in defending white-collar crimes like federal criminal medical/health care fraud charges. He knows the federal system and will make sure that your rights are protected. You need an experienced attorney to look out for your best interests. If you are facing federal criminal telemarketing fraud charges, call Attorney Joseph D. Lento at 888-535-3686 today for a consultation. You have the right to an attorney and a defense, and the Lento Law Firm will give you the representation that you need.