Health Care Attorneys serving Houston and all of Texas
The healthcare industry is highly regulated to protect the interests of the public. Government oversight and industry watchdog groups has made the need for experienced legal counsel critically important to practitioners, professionals and healthcare executives. The attorneys at the Health Law Group can help identify any potential risks, negotiate corporate transactions and to provide strategic representation and advocacy in complex litigations and potential criminal proceedings.
With experience in all aspects of healthcare law, the attorneys at the Health Law Group represent client interests in operational, regulatory and compliance and criminal matters. Our lawyers have helped many clients resolve some of the most complex legal issues including corporate structure, merger and acquisitions, government regulations and state and federal fraud abuse matters.
Our Houston Health Law Group helps healthcare providers including hospitals, physicians, treatment centers, clinics, dental offices and more. We understand the unique challenges that pharmaceutical manufacturers and durable medical equipment manufacturers face. Our healthcare lawyers can assist advise you on a number of legal issues including but not limited to:
Internal audits and investigations
Health Care Fraud
Contract Disputes
Criminal Defense
If you work in health care in Houston, Texas and are under investigation for, or have been charged with health care fraud contact an attorney as soon as possible.
Our Houston based attorneys are here to make sure that your rights and interests are protected throughout any investigations or charges in federal or state court. Our attorneys will ensure that you receive the best result possible in your individual case.
Due to the fact that health care fraud law violations in Houston may be under both federal and state law, both sets of laws are discussed in detail below.
Call for a Confidential Consultation
Health Care Fraud Laws in Houston, Texas
Texas Penal Code §35 – Insurance Fraud
In Houston, Texas health care fraud is made illegal under Texas Penal Code §35 – Insurance Fraud.
This law penalizes defrauding or attempting to defraud any type of insurance company. In this article, we will be focuses on the specific sections of the law that apply to health care law.
Under Texas Penal Code §35(a), a person commits insurance fraud if they, with the intent to defraud,
Prepares, or causes to be prepared, a statement that the person knows to contain false or fraudulent information and it is presented to an insurer; OR
presents or causes to be presented to an insurer a statement that the person knows to be false or fraudulent information.
Under this code there are different levels to the offense. These levels are differentiated as follows:
If the value of the claim is less than $100 then the offense is a Class “C” misdemeanor.
If the value of the claim is between $100 to $750 then the offense is a Class “B” misdemeanor.
If the value of the claim is between $750 to $2,500 then the offense is a Class “A” misdemeanor.
If the value of the claim is between $2,500 to $30,000 then the offense is a state jail felony.
If the value of the claim is between $30,000 to $150,000 then the offense is a third degree felony.
If the value of the claim is between $150,00 to $300,000 then the offense is a second degree felony.
If the value of the claim is more than $300,000 OR an act committed in connection with the offense places a person at risk of death or serious bodily injury then the offense is a first degree felony.
Federal Health Care Fraud Laws
There are a few different statutes in the United States that make up what is commonly known as federal health care fraud.
Each statute focuses on a different action or set of actions and each carries with it a different set of possible penalties if convicted.
Having so many statutes to be aware of and know the details they each require can be a daunting task for someone who does not practice law.
Reaching out to an attorney to have them guide you through the intricacies of the law will ensure you do not get caught up in the insignificant details.
The specific federal health care laws and regulations include:
Criminal Health Care Fraud
(18 U.S.C. §1347)
This is aimed to punish, criminally, those who knowingly and willfully execute, or attempt to execute, any thing that would defraud a health care benefit program of any money or other property under that program’s control.
If you are found guilty of criminal health care fraud you could face up to 10 years in prison and up to 20 years if someone dies as a result of the fraud.
Additionally, you may face fines of up to double the amount of the property you received as a result of the fraudulent scheme.
This is the only health care fraud statute that carries the possibility of jail time as a potential punishment. The rest of the statutes below deal with the many ways you could be held monetarily liable for actions that constitute health care fraud.
The False Claims Act
(31 U.S.C., Chp. 37)
This statute is used to prosecute, civilly, those professionals in occupational therapy offices who purposefully submit fraudulent or false claims to insurance companies in order to receive a payment.
For example, if a physical therapist bills a patient’s insurance company for physical therapy sessions that were never actually provided to that patient, that physical therapist may be charged with fraud under the False Claims Act.
If you are found guilty of a violation of the False Claims Act, you could face a fine of between $5,000 to $10,000.
In addition, a judge can order you to pay up to 3 times the amount that the government was defrauded of as a result of the scheme.
Call for a Confidential Consultation
The Physician Self-Referral law (Stark Law)
(42 U.S.C. § 1395nn)
The Stark Law is aimed at punishing those doctors who refer patients to receive specialized medical care from any facility or business that the doctor, or any member of the doctor’s immediate family, has some financial interest in.
For example, if an general practitioner, after seeing a patient, recommends that they need some type of imaging service, like a CAT scan and refers them to an imaging center.
If the physician refers the patient to a imaging center that the physician’s daughter owns that referral would be a violation of the Stark law.
The Anti-Kickback Statute
(42 U.S.C. § 1320a-7b(b))
This statute looks to punish the knowing and willful payment made in order to reward people or companies for patient referrals, or the generation of business, involving any item or service payable by the federal healthcare programs, including Medicare and Medicaid.
For example, if an oncologist pays a dermatologist to refer patients, specifically those who are Medicare beneficiaries, to come to the surgeon’s office.
The payments made in this example would make this a violation of the Anti-Kickback Statute.
If you are found guilty of violating the Anti-Kickback statute you face fines of up to $25,000, a prison sentence of up to 5 years, or a combination of both.
Other statutes that if violated would be considered health care fraud includes the Exclusion Statute (42 U.S.C. § 1320a-7).
Examples of Health Care Fraud in the United States
Diagnostic Company Owner Sentenced for Kickbacks, Health Care Fraud and Money Laundering
In April 2018, the owner of several diagnostic businesses and a medical equipment company was sentenced to 68 months ( about 5 ½ years) in federal prison.
In addition, he was ordered to pay $2,790,704 in restitution.
This all followed the guilty plea entered by Mark Edward Farias when he admitted to charges of conspiracy to pay kickbacks, commit health care fraud, as well as launder money.
Farias further admitted to paying kickbacks to the owner of another chain of clinics, at least $436,213.54 in total for access to at least 419 patients that were covered by the Federal Employees Compensation Act (FECA).
Farias also admitted that he submitted to up-coding claims for the kickback patients. This included claims for diagnostic testing that was not medically necessary and for diagnostic reports that were not produced.
For more information or the full Department of Justice DOJ press release, click this link or copy and paste the following URL.
Ambulance Company Owner and Brother Convicted in $6 Million Health Care Fraud Scheme
In December 2016, Kevin Olufemi Davies and his brother Melvin Olusola Davies were convicted on charges of conspiracy to commit health care fraud, health care fraud, and money laundering.
The two brothers owned and operated KMD Healthcare Services Inc. (KMD) from their home in Houston.
As a part of their guilty pleas, the brothers admitted that they used stand-in emergency emergency medical technicians (EMTs) who were employees of KMD in order to pass the state inspection that was necessary to enroll in the Medicare program.
Federal health care programs, like Medicare and Medicaid have certain requirements that must be met in order for them to pay out reimbursements. These requirements include:
The vehicles must be equipped to handle medical emergencies,
The patients must not be able to safely transported any other way, and
Their must be 2 individuals on every ambulance, including on at least one licensed EMT.
The brother admitted that they would transport patients in private passenger vans with only one EMT present. The EMTs would write up “ambulance run sheets” even though ambulance was used and the Medicare beneficiaries did not need ambulatory services.
Further, the brothers admitted that they would pay a Houston-based physician $500 per patient that was referred to their services.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
Call 844-239-1234 for a
Free Confidential Case ReviewClinic Manager Heads to Prison for Health Care Fraud
In March 2017, Verona Spicer, the owner of Elite P. Care Medical Services, was sentenced to 33 months (just under 3 years) in federal prison for her role in a more than $1 million health care fraud scheme.
In addition, Spicer was ordered to pay $560,718.62 in restitution to Medicare and Medicaid.
Spicer owned several Houston-area medical clinics. These clinics were then used the clinics to submit claims to Medicare and Medicaid for office visits that never actually happened and that were not supervised by the proper medical professionals.
Further, it was found that Spicer paid Dr. Jocelyn Pyles to sign patient medical records for patients that the doctor had not seen or examined.
In reality, a foreign medical graduate who was not licensed to practice medicine was the one performing the examinations.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
https://www.justice.gov/usao-sdtx/pr/clinic-manager-heads-prison-health-care-fraud
Katy Woman Sentenced in Health Care Fraud and Kickback Schemes
In November 2018, Joy Aneke was sentenced to a 36 month sentence (about 3 years) in prison, to be immediately followed by 3 years of supervised release.
In addition, Aneke was ordered to pay $2,760,464.57 in restitution to the Medicare program.
Aneke admitted that as the owner of Jadac Unique Health Services, and a few other Houston-area clinics she caused others to submit false and fraudulent claims to Medicare for services never actually provided to patients.
Aneke also ordered other employees to create false patient records to support the fraudulent claims submitted to Medicare. She would also pay kickbacks to patients who visited the clinics through the referral of a recruiter.
Aneke and her clinics billed approximately $5,963,675.88 for medical diagnostic services that were not provided or were not authorized by a physician. Medicare paid approximately $2,760,646.57 of those claims.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
https://www.justice.gov/usao-sdtx/pr/katy-woman-sentenced-health-care-fraud-and-kickback-schemes
Doctor Sentenced to Prison for Home Health Care Fraud
In July 2016, Dr. Warren Daily was sentenced to 63 months (5 ¼ years) in prison and was ordered to pay over $900,000 in restitution for charges of conspiracy to commit health care fraud.
Daily was also charged with:
two counts of false statements relating to health care matters;
one count of conspiracy to pay or receive “kickbacks”; and
one count of payment and receipt of health care kickbacks.
Dr. Daily will also be subject to 3 years of supervised release after he gets out of prison.
For approximately 4 years, Dr. Daily defrauded Medicare by authorizing Medicare beneficiaries for home health care services that were never needed.
The court found that Dailey conspired with a home health care owner in Houston.
Daily’s first criminal act was agreeing to sign fraudulent Medicare authorization forms certifying unnecessary services.
Daily’s second criminal act was receiving a monthly flat fee “kickback” from the home health care owner in exchange for signing these fraudulent authorization forms certifying unnecessary services.
It is estimated that due to Dr. Daily’s actions, Medicare paid out over $900,000 dollars for fraudulent home health care services.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
https://www.justice.gov/usao-sdtx/pr/doctor-heads-prison-home-health-care-fraud