Legal Services for Durable Medical Equipment Providers
Legal risks DME Providers face
Providers of durable medical equipment (DME) need to make sure that they are in compliance with the healthcare fraud statutes. Health care fraud and False Claims Act charges are common for DME providers. DME suppliers have been targets of several investigations especially after the increased amount of organized crime around DME.
Recently criminal organizations have been using DMEs as a way to bill Medicare and Medicaid for this equipment in a way to make large amounts of money. It is a common to see cases about providers where they were charging for high end equipment and providing low end equipment or even billing for equipment for patients that did not exist.
DMEs are a classification of medical supplies that can be used repeatedly between different patients, such as wheelchairs, walkers, lifts, hospital beds and oxygen monitors. These products are usually provided to nursing homes, hospitals and directly to patients through DME providers.
Most DME are covered by Medicare and Medicaid so it is common practice for providers to bill both of these entities. When there are problems with the bills that are submitted to Medicare and Medicaid you may face both criminal and civil charges.
As a DME provider you need to make sure that you are correctly providing and billing each instance where a piece of equipment is provided. You may become under investigation if the authorities find patterns of over-billing or are tipped off to a problem. I
If you are under investigation your first step should be contacting our experienced lawyers to defend you against allegations of fraud. When you are suspected of fraud you may face a lengthy investigation process and might eventually get charged. Having an attorney from the onset of a case will help your odds of defeating fraud allegations.
If you are found guilty of Health Care Fraud or under the False Claims Act you may face jail time and significant financial penalties. You should get ahead of any investigations by getting an attorney to help guide you through the investigation process.
Basic of Healthcare Fraud
Healthcare fraud covers a category of charges that all involve a scheme to make money that was not earned from insurance providers. DME providers need to make sure that when they provide any products that they are not in violation of healthcare fraud laws.
The two main federal laws that DME providers need to make sure they are in compliance with are Health Care Fraud 18 U.S. Code § 1347 and the False Claims Act. Besides these two crimes there are other fraud based statutes and other crimes not related to health care that you may be charged with however these two are the most common.
Healthcare fraud affects all parts of the industry especially patients and insurance companies. An instance of fraud with DMEs could result in patients not getting adequate care or the level of care they should be afforded. Healthcare fraud is also harmful to insurance companies especially Medicare and Medicaid because it drains their resources without any benefit confirmed.
Health Care Fraud 18 U.S.C. § 1347 makes it a crime to defraud a health insurance provider or fraudulently obtain funds from an insurance provider. There are several schemes that fall under health care fraud, such as, upcoding, billing for services not rendered, billing for non-covered services, ghost patients, improper procedures, and kickbacks.
For a DME provider the most common schemes that you may be charged for health care fraud are upcoding or ghost patients. These schemes are common and often prosecuted when providers charge for higher services or bill for products that are never used.
Violation of the Health Care Fraud statute could lead to jail time up to 10 years and criminal fines up to $250,000. If your violation of health care fraud results in serious injury you may face up to 20 years and if someone dies as a result of your health care fraud you may end up serving a life sentence.
If you submit bills to Medicare or Medicaid provides criminal punishment for knowingly making submitting false records or claims to the government under the False Claims Act. The violation of the False Claims Act may either be knowingly or if you are blatantly ignorant you may be held liable under this law. False claims charges for owners are common because if the owner is blatantly ignorant they may be charged.
Violations of the False Claims Act may come with a punishment of $11,000 for each false claim plus up to three times the damages to the government for the claim. Criminal liability under this law can be assessed only if someone knowingly makes a false claim, and the criminal punishment is a fine up to $250,000 and up to 5 years imprisonment.
If you as a DME provider and you set up a contract with hospitals or doctors’ offices you may be in violation of the Anti-Kickback Statutes. Kickbacks under 42 USC § 1320a-7b(b) involves the act of receiving a kickback is defined as knowingly receiving any money of any kind for a referral. If your company is receiving kickbacks you may face up to 5 years imprisonment as well as criminal monetary penalties up to $25,000.
Healthcare Fraud Investigative Process
If you become a suspect of healthcare fraud you might become under investigation where the government tries to gather evidence against you to convict you under any one of the fraud statutes. It is important to understand your liability for each specific wrong act so you should talk to our experienced health care attorney that will be able to outline what your liability will be criminally.
When an investigation begins against a DME practice all staff, management and ownership may be questioned by an investigator. It is important to speak to your attorney about your role in the business to assess any potential liability.
It is also important to understand the difference between an attorney representing you, your practice or your employees. If you retain the same attorney to represent all of these parties it may help coordinate efforts but there is a chance you might want to distance yourself from an employee who was participating in illegal activities.
If you are suspected of committing healthcare fraud the government may begin an investigation. In the field of DME providers it may be harder for the investigator to question and interview some patients to see what DMEs they received or they may perform an audit of your firm.
Separate from a criminal investigation you should work to audit or investigate internal to make sure you are in compliance with all of the health care laws. You should look into and routinely check on all of your employees to ensure compliance. This type of review of your own company can insure compliance and help you to address any current problems.
Investigations by the federal government will also likely involve questioning. If you or any of your employees are questioned you may request to have an attorney present for questioning. An attorney will help assert your rights and make the questioning process much easier for you.
An experienced attorney will help you throughout a government investigation by helping to work to assess the evidence and to help plan a strategy to deal with the investigators. Just because you are under investigation it does not mean that you have done anything wrong or that you will get charged but having an attorney from the onset of an investigation may increase your odds of defeating any healthcare fraud allegations.
Fraud is often detected when whistleblowers bringing a qui tam lawsuit. Whistleblowers are private citizens with insider information that file a lawsuit against a medical professional or group for fraud related activities. If there is a successful conviction of fraud the whistleblower may get between 15-30% of all money recovered by the federal government in the lawsuit.
If the Attorney General’s Office feels that there is enough evidence they will bring charges. After charges are brought there will be a grand jury hearing where the grand jury will decide if there is enough evidence to indict.
Before a grand jury hearing it is important to speak to an attorney to help you prepare for the hearing because there is a chance to get the charges dropped during the grand jury hearing.
When you are indicted your attorney and the government may work towards a settlement on the case or move towards dismissal of the case. If there is no settlement or dismissal your case will most likely end up getting a trial date.
Your attorney should work with you to review all of the evidence and prepare your best defense for trail. For all of your criminal convictions you will also have the right to have a jury trial before a jury of your peers.
Criminal Charges Associated with Healthcare Fraud
DME providers are particularly vulnerable for charges of health care fraud as it is involved with the mistreatment of needy patients. Often older or vulnerable patients are subject to schemes involving DME so the government is quick to protect these individuals. There are several charges you may face and there are certain practices you should be looking out for to make sure that you may not face criminal liability.
When you provide DMEs for patients you may get into trouble if you received patients through or via a kickback scheme. Kickbacks involve payments for referring patients to other practices or having patients referred to you due to a payment. Under these charges you have to be careful about your contracts that are formed with other practices especially in the field of referrals. You should have an attorney review all of your contracts to make sure you are in compliance.
There are several schemes that can lead to healthcare fraud. The topic of healthcare fraud is rather large and there are several different schemes that are all prosecuted by the federal government.
Billing non-existent patients is a common scheme for DME providers because they can state that they are supplying the equipment to patients for a set period of time, bill Medicare or Medicaid then have the supplies “returned”. For this scheme it is common for patients names to be made up or to start billing double for each piece of equipment.
Investigations into this are usually done by the DOJ and the Attorney General’s Office and prosecuted under the False Claims Act, Heath Care Fraud Statute and other fraud crimes. This specific scheme is also very common among organized crime rings so other agencies might get involved in the investigations.
If you are under investigation for operating a scheme of billing without rendering equipment to patients it is important to have an attorney that understands the government’s burdens of proof to fight against these charges. The government needs to prove that you in fact were responsible for this action to criminally prosecute you.
Upcoding is also very common with DME because you may charge for the top of the line DME when what you are providing is a far less valuable DME. This scheme is common for electric wheelchairs because the provider could bill for the most expensive wheelchair and provide a less valuable wheelchair to save money on its wear and tear.
If you participate in a scheme where you are over-billing for what you are proving it is important to know you may be held criminally liable under the False Claims act and for Health Care Fraud. The conviction of these might land you in jail and facing quite heavy monetary penalties.
For the up charging or billing for more expensive products you should speak to an attorney about what practices you perform and how you keep a detailed record. It is important to always keep a record of any billed activities so you can defend against these fraud claims.
Overall you can face a variety of different civil and criminal penalties so you should contact USTO make sure you are in compliance with the healthcare laws and especially if you are under investigation.
The investigation process into any healthcare charges can be long and cumbersome so having an attorney to speed up the process can really make a difference. When and if you are charged an attorney will be able to find out what evidence the prosecutor has to be able to defend against the evidence. An experienced attorney will know what problems face you as an owner.
Recent Cases of Healthcare Fraud involving DME's
Cases of providers of DMEs being prosecuted are quite frequent. DMEs are seen by many as a quick way to get money from Medicare and Medicaid without having to do much work. The increased activity of fraud among this group has led to a higher amount of investigations and prosecutions of fraud.
Owners and managers of DME companies may face liability if they are participating in a fraudulent scheme. In New York a group of managers and owners of a medical equipment company were charged with submitting $3.5 million dollars of false or faulty claims. The providers would bill for a product when in fact they were providing nothing or a far less expensive product such as a lift chair or recliner.
Committing an act of fraud in relation to a DME company might also mean a jail sentence. In Miami in 2015 a man was sentenced to serve 70 months in prison for his role in defrauding the federal government of about $11 million. After payments were made through Medicaid the defendant would pocket along with others in the firm the proceeds instead of using the money to provide services.
The profitability of this crime has also led several criminal organizations to pop up which also leads to several other violations in addition to healthcare fraud. In Los Angeles 73 people were arrested in 2010 for their connection to a criminal organization working in healthcare fraud. This group worked to defraud the federal government of about $163 million. This scheme was known as one of the largest groups found to defraud the federal government for healthcare fraud.
The Impact of Healthcare Fraud
There are several reproductions you may face both civilly and criminally for your actions as a provider of DME if you commit fraud. The range of punishments includes criminal charges with jail time, monetary penalties and reimbursements, loss of license, and irreparable harm to ones reputation.
One punishment that can have lasting effects on your career could be losing your medical license. The state or states you are practicing in may revoke your license to practice medicine if you are found to be providing equipment falsely. If you are not a medical professional and only a provider the medical community may chose not to work with you or your company if you have a bad record.
Health Care Fraud convictions may land you in jail up to 10 years, if your acts result in serious injury you may face up to 20 years, and if someone dies as a result of your health care fraud you may end up serving a life sentence. Under the False Claims Act you could face up to 5 years for submitting false reports to Medicare and Medicaid. Under HIPAA you also may face up to 10 years.
The sentences that could potentially befall you may not only result in imprisonment but also reflect negatively on you due to your criminal record. A criminal record will follow you around and will make it harder for you to get a job in the healthcare field.
The amount of money you may need to pay out if convicted or in settling a case might be very high if you violated healthcare laws. DME providers sometimes have to pay out millions dollars for schemes to defraud Medicare and Medicaid. Every year the federal government gets billions of dollars recovered from fraudulent claims, which come from successful cases and settlements with healthcare professionals.
Developing a Strategic Defense
The charge of healthcare fraud can be quite severe which is why it is so important to get ahead of any allegations of fraud. Work with one of our experienced healthcare fraud attorneys to develop a defense strategy that is best for the unique circumstances of your case.
During every stage from investigation to trial there is a chance to defeat these allegations. You should work with your attorney to describe the facts of your case including all information regarding the potential crime and the information about your DME practice.
In addition to developing criminal defense strategies we will take a proactive examination of your business to ensure regulatory compliance and to identify any potential risks. Our firm has experience in handling complex healthcare fraud cases and can provide insight into specific issues that may be a concern to an individual or the business
When you are not in compliance with the healthcare laws you should work with an attorney to remedy these problems. When you are not in compliance with the law you may need to report to avoid making matters worse but your attorney will know how and when it is proper to report.
There are several actors usually responsible in schemes involving DME fraud. Because of this the federal government might be quick to implicate as many people as possible in the scheme. It is important to work with your attorney to help determine your liability based on your involvement in the scheme. If you unknowingly were participating and had no way of knowing you might have a defense.
Sometimes patients report problems with their DMEs. An example of this is when a patient is told they are going to get a state of the art piece of equipment and they receive what they consider a basic or inferior piece of equipment. When this happens once or throughout a series of times the government may begin investigation. It is important for you to keep detailed accounting of all billed items and what was provided to avoid these problems and to help combat any charges.
With DME fraud cases you may be charged with a variety of charges including conspiracy and organized crime type of charges. Our attorneys are experienced in handling a wide variety of cases and will be able to work to fight against each charge. Sometimes unfounded charges are also brought in an attempt to throw the book at you and see what sticks, and when this happens your attorney should work to have all unfound charges dropped.
When you are suspected of committing healthcare fraud your attorney should also work with you to get the details of your case to see if there are any possible defenses. One possible defense could be that you were not the one who committed the offense. You may also show that if you committed an offense you lacked the required mental state needed to prove a criminal conviction, which is at least knowing or blatant ignorance.
The best way to avoid any problems as a DME provider is to understand the law and to work in compliance with it. You should always make sure you are billing for the correct items, providing products when you bill and you need to keep detailed accountings of all your transactions.
Every level of medical professionals need to be aware of how their actions may put them in criminal liability. It is also important for DME providers to understand what liability may befall you for doctors fraud or fraud from other employees at your company. Work with our attorneys to ensure compliance and to defend against allegations of fraud.
Questions you may have about compliance or remedying past problems can be answered by our experienced criminal healthcare attorneys. You should have a plan in place to address all past problems and how to go forward in compliance with the law.
When you are under investigation your first step should be contacting an attorney. At every step of your case there is a chance for an attorney to help defeat allegations so it is never too soon to contacts us. Working proactively against healthcare fraud allegations will help you win your case.
Our attorneys understand what problems you may face as a DME provider. We know the intricacies of the law and how to defend against your charges. With our experienced attorneys we will be able to create a custom plan centered around you and defeating these allegations of fraud. Contact us today to help fight against any civil or criminal charges you may face.