Co-payment Fraud Attorneys
Generally, copayment fraud involves charging too high of a copay from patients; or not collecting copayments in order to get more money from an insurance company. These acts may lead to charges of health care fraud.
What is Health Care Fraud?
Health care fraud, which is made illegal under 18 U.S.C §1347, is providing false information to an insurance provider in order to obtain money or other property from the provider.
The federal crime requires prosecutors to prove 4 elements in order to obtain a conviction for health care fraud. These elements are:
- Knowingly or willingly attempts to execute.
This means that the defendant must have provided the false information knowing that it was false, a simple mistake of fact would not suffice.
The defendant must have had the intention that the false information or omitted information be submitted to the insurance company. In addition, the insurance provider would rely on that information and send money or property in return.
- A scheme or artifice
- Through false or fraudulent means
Fraud, generally, is the deliberate deception of another in order to secure an unfair or unlawful gain or to deprive a victim of a legal right.
Fraud differs from abuse of position as a medical professional or employee. Abuse is an action that is inconsistent with the general practices of the medical industry. Fraud is the exploitation of fact in order to receive something of value.
- Obtain property or money from a health care benefit program.
Under 18 U.S.C. §24(b), a health care benefit program is any public or private plan that provides medical benefit, item, or service is provided to any individual or provides the payment for those things. There is no knowledge of, or intent to violate, the federal statute necessary.
By providing an insurance company with false or misleading information and receiving property based on that false information, you may be held liable for fraud.
Further, this statute does not simply apply to licensed medical professionals. Non-licensed individuals, medical practice owners, health care businesses and even universities may be held liable for health care fraud.
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Possible Punishments for Health Care Fraud
If you are ultimately convicted on charges of health care fraud based on your actions as a health care assistant or medical service employee there are severe penalties that you will be facing. For your role, you may receive up to 10 years in prison. If, as a result of the fraud, someone suffers from death or serious bodily injury then you may receive up to 20 years in prison.
In addition, there are severe fines you may face for your role in a federal health care fraud scheme. The fines range from $250,000 for an individual defendant or $500,000 for a defendant organization.
The judge in your case may also choose to impose a fine of up to double whatever pecuniary gain was made as a result of the fraudulent scheme. In addition to criminal penalties, there are several civil penalties and fines that may be imposed.
How Will a Health Care Fraud Case Proceed?
- Enforcement of the Statute
There are several government agencies that are tasked with enforcing the federal health care law statute.
The “heavy lifting,” so to speak, typically falls into the Department of Health and Human Services Office of Investigations (HHS-OI) since they are charged with the oversight of the Medicare and Medicaid programs.
The Federal Bureau of Investigation (FBI), the Medicare Strike Force, and the United States Department of Justice (DOJ) will also help in the investigations and enforcement of the statute.
- Investigations into Potential Violations
Investigations into potential fraudulent conduct can begin in many ways. An investigation may also begin as a result of questionable results from a Medicare billing audit or other typical investigation.
It is important to note that if you become the subject of a health care fraud investigation, you should contact an attorney immediately.
During the course of a search, you should comply with the warrant you are given but do not answer any questions or make any statements without your counsel present. You make risk making additional incriminating statements or implicate yourself in a crime.
The DOJ will file charges in the appropriate federal jurisdiction.
The “jurisdiction” means which court can hear the case. This determination is generally made based on where the criminal activity took place but may also be found to be in the place where the victim(s) are located or where the defendant lives.
It is imperative to enlist an experienced attorney as soon as possible. Having someone to protect your rights and interests at every level or a case, from investigation to sentencing – if it comes to that, will help to make sure you receive the best result possible.
What You Can Do
First and Foremost, contact an attorney. Even if you are not under investigation and attorney can help to ensure that you never become the victim of fraud. Our attorneys are a wealth of knowledge in medical billing and coding, the different health care fraud schemes that commonly affect home health aide services, and the importance of the confidentiality of your patients.
This knowledge will help them to craft an individualized plan for you and/or your business to be proactive against the possibility of health care fraud charges. Especially if the charges end up dropped or the investigation does not show evidence of fraudulent activity.
It is also important to keep in mind that you should never speak to investigators without your counsel present because you do not want to make statements that could be incriminating or implicate you in criminal activity, or that could be spun to do so. Let an experienced attorney look after you if you are facing a complex legal issue.