Healthcare Fraud

Man with a mask

Healthcare fraud is a type of white-collar crime that occurs when a healthcare claim is filed or reported in an attempt to gain a profit. Pharmacies, hospitals, and doctors are in positions where they can be accused of stealing taxpayer money through fraud. These are serious charges that are almost always prosecuted.

What Is Healthcare Fraud?

Healthcare fraud is prosecuted under 18 U.S.C. § 1347. A person violates this statute if they knowingly and willfully executes, or attempts to execute, a scheme to (1) defraud any health care benefit program; or (2) obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services.  

Additionally, the False Claims Act 31 U.S.C. §§ 3729-3733 is a federal law that was enacted in 1863 because Congress wanted to stop suppliers of goods from defrauding the Army during the Civil War. This law made it illegal to submit a false claim to the government or cause another party to submit a false claim in order to get paid for that claim. 

Any individual or corporation who knowingly and intentionally commits an act of defrauding any healthcare benefit program is liable for treble damages (triple the amount of the compensatory damages awarded to a plaintiff), plus penalties. The U.S. government and individuals can go after individuals or corporations for healthcare fraud. A provision in the Act called “qui tam” enables a private citizen to file suits on behalf of the government against parties who have committed fraud against the government.

Types Of Healthcare Fraud

There are many different types of fraud. Because of that, there are many types of defense for these accusations. Billing can be erroneously submitted either to a private health insurance company, Medicaid, Medicare, or the patient. The types of healthcare fraud are:

  • Receiving or offering kickbacks or perks for referrals, prescribing certain medications or meeting a certain quota of patients
  • Billing for unnecessary services 
  • Billing for services or equipment that wasn’t given to the patient
  • Up-coding, or when a bill is submitted for a service that is more expensive than it should be

Making any false statements to Medicare or Medicaid, in general, must be avoided by all employees. But proper training is essential so that employees working in clinics, hospitals or private facilities can do their very demanding and complex job accurately.

Know Your Rights

When law enforcement shows up, it is imperative that you do not lie to them. A lot of the time, defendants are caught off guard and they’re not prepared to answer any questions by investigators. But you still have to take the right legal steps. First, with calm and courtesy, excuse yourself from the conversation and call a criminal defense attorney. If they object, say that you will be in contact with them right away, or come right back. Next, call the Law Office of Vikas Bajaj to represent you as your defense attorney. You will receive further instructions on what to do after this point. 

Remember that you have the right to remain silent, and that is important to keep in mind because the prosecution will definitely use what they have against you. So, before you try to say anything that you think will help or put you in a better light, stop. It is not uncommon for prosecutors to intentionally twist what you’ve said to help their argument. The Fifth Amendment protects your right to remain silent, and the Sixth Amendment protects your right to legal counsel.

Federal Sentencing Guidelines

Under §2B1.1. Larceny, Embezzlement, and Other Forms of Theft; Offenses Involving Stolen Property; Property Damage or Destruction; Fraud and Deceit; Forgery; Offenses Involving Altered or Counterfeit Instruments Other than Counterfeit Bearer Obligations of the United States, the base offense level for Healthcare Fraud is: 

  • 7, If (A) the defendant was convicted of an offense referenced to this guideline; and (B) that offense of conviction has a statutory maximum term of imprisonment of 20 years or more

In addition, if the loss exceeds $6,500 then there is a range of enhancements that can add between 2 and 30 levels to the offense, which are all included in the United States Sentencing Commission Guidelines Manual.

Federal Criminal Defense

Healthcare fraud convictions can lead to serious consequences including losing your license, jail time anywhere between 5 and 20 years and fines. You can also be permanently excluded from receiving payments from Medicare or Medicaid.

When you receive a target letter or target notice from federal authorities, then you will need to act fast to hire an attorney. There are honest mistakes that happen with coding, and sometimes people who are trained incorrectly or who don’t know the whole process report what they think are crimes. There are a variety of other reasons why someone could be accused of healthcare fraud, and their misunderstanding or mistake can have a serious impact on one’s practice or career. If you are a healthcare provider, individual, or corporation, and you are being accused of healthcare fraud, then call the Law Office of Vikas Bajaj today.