Health Care Fraud — Serious Federal Charges
The last thing a doctor, nurse, licensed medical professional or health care owner wants to do is discover newly hired staff submitted miscoded or erroneous bills to Medicare or Medicaid. The federal government could think an innocent mistake was part of a fraudulent billing scheme and begin investigating you, your patients, your pharmaceutical representatives and medical equipment suppliers.
In 2016 The Medicare Fraud Task Force of the Department of Justice (DOJ) conducted a massive 900 million dollar false billing sweep. The statistics of that sting are extraordinary — 301 people were charged and 60 defendants were arrested. DOJ charged the defendants with conspiracy to commit health care fraud, violations of the anti-kickback statute, money laundering and aggravated identify theft.
If you’ve inadvertently become the target of a Medicare or Medicaid fraud investigation, you’ll need competent legal advice immediately.
What Is Medicare And Medicaid Fraud?
There are many ways to cheat Medicare and Medicaid. Most schemes involve improper coding and billing for services. Medicare and Medicaid reimburse providers using a prospective payment system (PPS) based on medical codes assigned to an illness. The government also factors in the reasonable cost to treat the patient and reimburses the doctor of hospital-based on the illness treated (medical code) and the cost charged (reasonable rate).
Fraud occurs when a hospital or medical professional cheats Medicare or Medicaid in any of the following ways:
- Charging for tests, services or supplies not actually provided,
- Falsely stating how many hours were spent (i.e., routinely adding fifteen minutes to the bill),
- Inflating the bill by ordering tests or services not really needed,
- Requesting a full panel of tests when only one or two were needed
- Billing for routine supplies (i.e., band-aids, lubricants, gloves, masks or monitors),
More complex mistakes are viewed as schemes intended to bilk the government out of money. As former attorney General Loretta Lynch observed “[health care fraud] is not an abstract violation or benign offense. It is a serious crime.”
It’s a serious matter if anyone with a Medicare or Medicaid fraud task force examining your practice’s billing for these errors:
- Upcoding – This involves enhancing the illness with which a patient presented to a more severe, but related medical condition (coding bronchitis as pneumonia to get a higher reimbursement rate),
- Unbundling – Taking a procedure such as an appendectomy and separating out each component in order to bill by a component of the procedure (per component might result in higher a higher reimbursement rate),
- Unreasonable costs of goods or services – Ordering unnecessary tests or services that are inappropriate for the diagnosed illness (i.e., psychotherapy for an Alzheimer’s patient),
- Pharmaceutical Fraud – The greatest violator of fraud through deceptive off label promotions, kickbacks, adulterated products, and Medicaid rebate fraud.
Criminal Penalties For Healthcare Fraud
You’ll face hefty fines, even for misdemeanors, and jail time for healthcare fraud and false claims submitted to Medicare and Medicaid. For example, a fraud charge filed under the False Claims Act is a federal crime punishable by fines and up to five years in prison. The fines start at $250,000 for an individual and $500,000 for a corporation, for a felony, and $100,000 for an individual and $200,000 for a corporation for a misdemeanor.
Whether or not you are a candidate for jail time for Medicaid or Medicare fraud depends on a variety of factors including the amount of money the government estimates you bilked out of Medicare and Medicaid, whether you have a previous criminal history, whether any restitution has been paid back, and who the judge and prosecutor are.
There’s a growing trend with the federal government to pursue white collar crimes involving the provision of medical services. It’s where the money is. The first thing that any good defense attorney would do is analyze whether you have a defensible case or not.
Charged With Medicaid Or Health Care Fraud?
We Will Fiercely Challenge The Evidence And Defend You
Houston defense attorney Paul Morgan has experience defending medical practitioners, health care owners and individuals wrongfully accused of defrauding the government’s health care system.
If you believe you’re under investigation for improper billing or defrauding Medicare or Medicaid, let’s discuss your options. All conversations and communications are 100% confidential and protected by law.