Health Insurance Fraud Legal Services
Why speak with our Health Insurance Fraud Lawyers?
The attorneys at the Health Law Group have experience helping healthcare professionals with complex legal matters. We understand the healthcare industry and the legal issues that are unique to physicians and healthcare professionals. Our lawyers have extensive experience in the white-collar criminal defense field. Utilizing a skill set honed by experience in complex cases, our lawyers offer clients practical legal strategies for defending against an accusation or charges of health insurance fraud.
An accusation of health insurance fraud is very serious allegation. Anyone accused of such a crime is facing the possibility of a lengthy jail sentence and potentially large fines. Not to mention for health care providers, a conviction will likely end that person’s career in the health care industry.
Over the last several years, legislatures have been mounting fines and jail time on people convicted of health insurance fraud in an attempt to dissuade fraudsters. In turn, prosecutors are looking to put fraudsters “away” when caught defrauding insurance companies.
What will happen if accused of Health Insurance Fraud?
In addition, an accusation of health insurance fraud can severely affect your ability to continue practicing as a health care professional, even if you have not been convicted. We all use health insurance, in one way or another. An accusation can hamper your ability to practice because patients and the public may question your integrity.
Therefore, you need an advocate on your side who will not allow an accusation to affect the way you live your life.
If you are facing a charge of health insurance fraud, call us now. Your situation is serious; our lawyers are serious.
What is Health Insurance Fraud?
In its simplest form, health insurance fraud is the filing of a health care claim to turn a profit. The fraudster will knowingly submit a claim to the insurance company for certain services that are either wholly or partially fraudulent.
Statistics illustrate to us how severe health insurance fraud is in the United States. The National Health Care Anti-Fraud Association (NHCAA) states that in 2011 there was $2.27 trillion in health care charges consisting of over $4 billion in claims. While the exact number of health care fraud is not known, the NHCAA states that it was in the 10s of billions of dollars.
To be convicted of health care fraud, you must have deliberately and dishonestly committed the act. This can be via misrepresentation of what was diagnosed or dishonest billing practices. Either act is considered fraud. Similar to health insurance fraud, health care abuse is a practice that is inconsistent with regular business norms and practices in the health care industry that results in unnecessary reimbursement.
The following are some common examples of practitioner health care fraud:
1. Providing a prescription for a drug that is not needed;
2. Filing duplicate claims for a service that was not provided;
3. Altering names, dates, etc. to reflect a fraudulent scheme;
4. Billing for a service that is not covered as if it is covered;
5. Charging excessively for various medical supplies;
6. Upcoding, which is falsely billing for a pricier treatment than the treatment provided;
7. Enrolling in government-assisted programs, like Medicare and Medicaid, without qualifying for
8. Unbundling, which is billing at each phase of treatment as if it were the whole treatment; and
9. Conspiring with patients to not use their prescriptions and instead sell those drugs on the black market.
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Who usually commits Health Insurance Fraud?
Often, practitioner health care fraud is practiced by medical providers on patients who are unsuspecting. Most patients have little or no medical knowledge and must, therefore, rely on the practitioner’s knowledge entirely. This trust allows practitioners much leeway when diagnosing patients and prescribing them medicines.
In addition to practitioner fraud, health care fraud can be at the organized crime level. Organized crime may bill insurance companies from fictitious clinics. The organized crime organization may be based outside the country, further adding to the intrigue.
Of course, almost anyone can commit health care fraud, even if that person is a patient. If a patient tells his doctor about a fictitious ailment and the doctor provides services followed by the pharmacy providing services, then the patient committed health care fraud.
Legalities of Health Insurance Fraud
In 1996, Congress passed the Health Insurance Portability and Accountability Act, better known as HIPAA, that has provisions dealing with health care fraud. In its basic form, those who commit health care fraud face 10 years in federal prison and a hefty fine. What’s more, if the fraud results in an injury to a patient, the fraudster would be facing 20 years in federal prison.
In addition to federal laws that tackle health insurance fraud, state laws also address this fraud. In New York, for instance, the New York Penal Code states five degrees of health care fraud. In short, the Penal Code’s five degrees are as follows:
- Fifth Degree – defrauding one health care plan one time.
- Fourth Degree – defrauding one health care plan over a one-year period that exceeds $3,000.
- Third Degree – defrauding one health care plan over a one-year period that exceeds $10,000.
- Fourth Degree – defrauding one health care plan over a one-year period that exceeds $50,000.
- Fifth Degree – defrauding one health care plan over a one-year period that exceeds $1,000,000.
What is the legal term for the Agency?
It is important to note that the legal term “agency” is very pertinent. That is to say when someone acts as an agent of another. The primary is responsible for the agent’s actions. In a general employment scenario, someone who works for a doctor is the doctor’s agent. If the employee bills fraudulently, the doctor can be held legally responsible because the employee is the doctor’s agent.
Also, note that contractors are generally not considered agents. Therefore, if a doctor outsources the billing to a medical billing company and that company fraudulently bills without the direction of the doctor, there is usually no agent liability.
Federal and State Cooperation
In addition to the HIPAA penalties, Congress enacted the Health Care Fraud and Abuse Program, also known as HFAC, to coordinate federal and state law enforcement with respect to fighting health care fraud.
Since 2010, the coordination between the various agencies has increased. The Department of Health and Human Services, the Office of the Inspector General, and the Centers for Medicare and Medicaid Services have jointly sought to fight against healthcare fraud. This is primarily in the government-funded healthcare space but also concerns the private health care space.
Through HFAC initiatives, various law enforcement groups use different tools to pursue fraud in the health care sector. The coordination allows for law enforcement to monitor possible and potentially fraudulent cases by gathering intelligence and then sharing that intelligence with other agencies. Through the coordination, HFAC alone recovered over $3 billion in health care fraud just in 2016.
What did the Government implement to avoid Health Insurance Fraud?
With respect to Medicare and Medicaid fraud, the government implemented a digital program that contains analytics of how people use Medicare and Medicaid, similar to how credit card companies track users.
Specifically, the government employed Computer Assisted Coding, known as CAC, to track possible fraud. CAC codified how billing works, making it harder for fraudulent billing due to a more confirmed system. Based on these analytics, the government is able to perceive possible fraud and act prophylactically before actual fraud takes place.
Consequences of Health Insurance Fraud
According to the NHCAA, health care fraud drives up the price of health insurance in a significant way. Because health insurance is pooled based on actuarial numbers, the more health-related concerns mean the more health care costs. A significant portion of such health care cost is from fraud. Therefore, as fraud increases so do the price of health care.
Health Insurance Fraud in the News
Last year, through the joint cooperation of HFAC, over 600 individuals were charged with health care fraud. This included 165 practitioners. The fraud was related to overbilling both Medicare and Medicaid. The cost savings, according to the HFAC press release, was over $2 billion.
Here are some stories about Health Insurance Fraud:
In 2018, DaVita Medical Holdings paid a $270 million fine to the Department of Justice as part of a health care fraud crackdown. DaVita Medical Holdings looked through charts of seniors to find more medical issues so they can bill Medicare, according to the Department of Justice.
A similar case was Health Management Associates, which paid a $216 million fine to the Department of Justice. Fraud charges included overcharging Medicaid for patient procedures.
A few months ago, a Houston-area doctor was convicted of running a fraud scheme and fined $20 million to the Department of Justice. The doctor was charged with falsifying reports, sending patients for unnecessary medical treatment and then billing that treatment, and instructing billing staff at the Houston hospital to falsify reports.
An Alabama doctor convicted of health care fraud was sent to jail for five years and ordered to pay $15 million in restitution.
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How to defend against a charge of Health Insurance Fraud
Like all other criminal cases, health care fraud is a criminal charge and guilt can only be established, in a court of law, if the prosecution proves such guilt beyond a reasonable doubt. If the prosecution presents evidence that is compelling but does not rise to the level of beyond a reasonable doubt, the verdict will be not guilty. When facing a charge of health care fraud, it is the prosecution’s duty to prove the case.
If the Evidence is Insufficient, There is No Case.
Insufficient evidence is the most common defense of health care fraud. For instance, if a medical practitioner is charged with health care fraud, a defensive strategy is to view the facts of the case.
Did the practitioner reasonably believe that a patient may be suffering from a certain ailment? Did the practitioner, as the patient’s doctor, do the right thing by looking at the patient’s records to determine whether the patient has a condition? Or was the practitioner scouring records to manufacture problems? If a court has doubt about this issue, the verdict is not guilty due to insufficient evidence.
Another defense is a claim that the alleged fraud did not occur knowingly. As mentioned, one can only be guilty of health care fraud if he or she committed the knowingly. If a practitioner told something to the billing department and the billing department incorrectly billed the insurance company, the practitioner seemingly did not commit a crime knowingly; rather; it was a misunderstanding between the doctor and the billing team.
Are you looking for an Attorney to defend you against a charge of health insurance fraud?
Charges of health insurance fraud can have a devastating impact on your family, your business, and your future in the profession. Your freedom is in jeopardy; you may be facing significant jail time.
Health care fraud is viewed as a public nuisance due to its effect on insurance premiums, if charged you will likely be facing a very vigorous prosecution. Prosecutors often are determined to put the “public nuisance” away for a long time.
That is why you need an experienced defense attorney skilled and knowledgeable in defending against health care fraud accusations. Prosecutors want to demonstrate to the public that they are trying to keep insurance rates in check; you need a strong advocate who will protect your rights.
Call Us Now
Our attorneys understand the seriousness of these prosecutions and can help you understand the charges that are being brought against you. We can accompany you to interrogations and ensure that your rights are not violated. Ultimately, our goal is to help you establish a legitimate defense.
We have the knowledge and background to defend anyone prosecuted for staging an accident fraud successfully. Our experience includes representing the industry and corporate clients in cases like these.
If you or someone you love has been charged with health insurance fraud, call our attorneys for a free legal consultation.