Phantom Patients Investigations
Being investigated for health care fraud can happen for many reasons. “Phantom Patients” are a specific area within the realm of healthcare fraud. This article will help to give you a basic understanding of health care fraud and phantom patients.
There is a specific area within health care fraud that focuses on doctors and their billing practices. While not necessarily a new area of fraud, the federal government noticed a spike in fraudulent billing by doctors for services provided deceased people. These services can come in various forms, but are not actually being performed and can result in criminal charges.
Using “phantom patients” to conduct health care fraud is a federal crime. The statutes for this crime are complicated, the procedure is strict and the punishment is far more serious, resulting in higher penalties. A federal criminal defense attorney who focuses on federal cases has the knowledge and skills that allow for a successful defense. Even though this charge seems like it could be a simple mistake, the types of evidence will require a thorough review followed by litigation provided by the representation of a federal criminal defense attorney.
Health Care Fraud Statutes
Health Care Fraud 18 U.S.C. § 1347
The generally applicable statute for health care fraud is 18 U.S.C. § 1347. As aforementioned, this statute is broad and regulates actions by individuals seeking health care benefits and those providing health care services. The statute reads in part:
(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—
(1) to defraud any health care benefit program
(2) to 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
(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.
This statute does not provide any specific acts that would cause you to commit health care fraud. Rather, the statute merely says that you cannot receive the payment of or the actual receipt of health care benefits, items, or services by committing any fraudulent act against a health care program.
In the instance that you are being investigated or are charged with phantom patients, the government is looking at the medical services you have claimed to provide in relation to a deceased or non-existent person on the day you provided those services. Therefore, your alleged violation of the statute would relate to you receiving payments or items based on a fraudulent statement.
False Statements 42 U.S.C. § 1320a(1)-(6)
Health care fraud is closely related to making false statements which fall under 42 U.S.C. § 1320a(1)-(6). This statute regulates the statements that you can make to the government to receive a benefit of a health care program. By violating this statute, you can be criminally charged by the federal government.
If you are charged, the federal government would need to prove that 1) you made a false statement to the government, 2) you knew the statement was false, and 3) that the government relied on your statement which caused them to act (issuing a payment or good).
This statute can apply to your alleged actions if you are accused of billing for services that you did not provide. These bills of services are considered statements. If the statements being made are untrue, they qualify as false statements.
Examples of Phantom Patients as Health Care Fraud
Of the more common types of phantom patients as health care fraud is to bill for services provided when a patient does not exist. For example, a doctor was charged with claiming that he made multiple office and home visits to patients. Upon investigation, the authorities looked at the specific days that the doctor claimed to have provided services to certain patients and found that many of those patients were already deceased.
Another example of phantom patients as health care fraud has to do with prescriptions. In Illinois, a Paramedic Supervisor was charged with healthcare fraud for claiming that he administered the Schedule II narcotics, Fentanyl and Morphine, while rendering aid to injured individuals who did not exist.
These examples are only a couple of the many ways that you can be charged with health care fraud on a theory of phantom patients. If you make a claim that a patient needs a special type of equipment (either for their home or for your office to provide care) and the patient does not exist, you can be investigated and charged for health care fraud.
Penalties for Phantom Patients as Health Care Fraud
The penalties for phantom patients as health care fraud is provided by 18 U.S.C. § 1347. Essentially, the basic penalty for all health care fraud is a fine and up to 10 years in prison, followed by a term of supervised release (probation).
For sentencing purposes, the court will look at the crimes committed and the facts of the case. Both your defense attorney and the prosecutor will be able to make arguments to attempt to sway the court for a lighter or heavier sentence. The court can look at the total amount of profit you made off of your acts, double it, and substitute it as a statutory fine.
Loss of Jobs and Credentials
Just by being charged with this crime can result in loss of employment. If the case ends in a guilty plea or verdict, that likelihood grows.
Secondly, there are licenses that you could lose. One of the examples above explained that the paramedic was dealing with narcotics in his alleged fraud. There is a possibility that if you have a DEA narcotics license, you may have to forfeit that license.
The charge of phantom patients as health care fraud will likely come with additional charges since at some point, you have to use a person’s personal information to falsify the documents. Additionally, you have to use a type of technology to submit those claims. As you can see, one act can lead to many charges.
These charges can include:
● Identity theft (for using personal information without authorization)
● Wire fraud (for submitting the false statements though technology)
● Money laundering (if you moved money to avoid being detected)
● Providing false statements to the government (see above)
● Conspiracy (if you are accused of these acts as part of an agreement with another)
How Phantom Patients as Health Care Fraud are Detected and Investigated
Generally, the investigation in the area of phantom patients is all about the data or information you provide to receive the health care benefits. This data is most likely going to include personal information of a patient, date of services, and types of services, all of which is stored onto a system.
In the earlier example of the doctor who claimed false house visits, he entered all the information related to his services on to the Current Procedural Terminology (“CPT”). The government used that technology, reviewed it, and found that the claim for those services was false.
Medicare Task Force
The federal government has a large unit that was created in 2007 called the Medicare Fraud Task Force to detect Medicare fraud. The task force is a combination of agencies and has locations around the country including: Miami, Florida; Los Angeles, California; Detroit, Michigan; Houston, Texas; Brooklyn, New York; Baton Rouge and New Orleans, Louisiana; Tampa and Orlando, Florida; Chicago, Illinois; Dallas, Texas; Washington, D.C.; Newark, New Jersey/Philadelphia, Pennsylvania; and the Appalachian Region.
Because of its large size, the Medicare Fraud Task Force can conduct audits and sort through all kinds of data, and a lot of the investigations start at the data stage. At that stage, they data mine by looking at billing software, claims, services, etc. This data is information that you have submitted or are likely required to submit.
Investigation vs. Being Charged
If this is a health care fraud case, the investigation is unlikely to be a quick matter, and you may only find out mid-investigation. You may hear that you are being investigated, maybe by someone who was subpoenaed or maybe even because the investigating agency has contacted you.
At the investigation stage, authorities are still trying to determine whether a crime has been committed and are gathering evidence to build a case against you or not. At this point, you have not been charged.
Being charged with a crime can look a couple of different ways: First, but not always, it can start with a criminal complaint. Next would be the formal charge, which can happen though indictment by grand jury or information at a preliminary hearing. Once these steps are completed and an indictment has been filed, you will be formally charged. At this point, usually, the investigation is complete, though there are instances where the prosecutor or law enforcement attempt to get more information.
If you find that you are being investigated for a federal crime, you should contact a federal defense attorney right away. Even you have not been arrested, you may be contacted by the investigating agencies who are seeking information. As you are likely aware, things you say to law enforcement can be used against you if the case is indicted and goes to trial. You will need the representation of a federal defense attorney to determine your response.
When a case goes to trial, almost any evidence collected is presented to the jury, so when being questioned by law enforcement at any stage, you should have a federal criminal defense attorney present.
Once your case is pending trial, your federal criminal defense attorney will get a better understanding of the charges. You and your federal criminal defense attorney can discuss trial strategies and develop defenses. Your federal criminal defense attorney will be aware of the various issues surrounding your case and will be able to utilize those issues to benefit your defense.
Importance Of Having a Defense For A Federal Offense
Federal crimes come with more consequences than state crimes. This is often because of the high penalties, the number of possible years in prison, the large fees, and the rights lost due to a conviction. Because of these consequences, it is important that you have a defense.
Defenses can come in various forms, including factual and statutory. A factual defense could be that the federal government has only found one instance where you are alleged to have committed phantom patient health care fraud. An example could be one instance of an error in your data reporting. This type of offense will be less successful depending on the amount of evidence that the federal government has against you.
A legal defense could be that you are charged with a crime where the statute of limitations has run. In practically every case (with exceptions to homicide and a couple of other crimes), there is a time limit in which the government is required to file charges against you. If the charges are filed after that time limit, the case cannot move forward.
What Do You Do If You Are Accused of Phantom Patients
If you are told about specific phantom patients, it may be best to stop requesting benefits for those patients. If you are offered a deal for cooperation, ask to speak with an attorney.
Sometimes, the benefit you receive from testifying against other defendants does not outweigh the other possible outcomes of your case. If the government requests for you to answer questions or provide documents, seek the advice of an experienced federal criminal defense attorney.
Contact an experienced federal criminal defense attorney, one who is experienced and can thoroughly investigate your case to identify issues and defend the case against you. This is important- it could be the difference between innocence and guilt and your freedom.