Medicare Fraud Attorneys
Medicare is the health insurance program, run by the federal government, that provides coverage for people who are 65 years of age or older, certain young people with disabilities, and people with end-stage renal disease.
Medicare works just like any other insurance company. You go to the doctor, who will perform an exam and order tests and then bill Medicare for the costs of those services.
Both federal and state governments have installed watchdog agencies to prevent Medicare fraud, to investigate claims of Medicare fraud, or to prosecute those who are alleged to have committed Medicare fraud.
Below, we will discuss:
- Medicare Fraud under both state and federal law;
- Penalties for committing Medicare fraud under both state and federal law;
- Defenses for those that have been charged or accused of Medicare Fraud.
Our attorneys focus on various white collar crimes, like Medicare fraud, and various other government investigations. If you have been charged with Medicare fraud, or are the subject of a government investigation, contact an experienced health care fraud attorney as soon as possible.
What is “Medicare Fraud?”
“Fraud” is the intentional misrepresentation of a fact with the purpose of making a third party act, which results in an injury or damage.
“Medicare fraud” follows the same basic definition but with the additional element that the third party is the United States government’s Medicare program.
Since Medicare is a federal program, much of the investigations into and ultimate criminals charges come from the federal government. Although, Medicare fraud is illegal at the state level as well. Both are discussed in more detail below.
When a person commits Medicare fraud, they are committing fraud against the United States, as it is a federal government run program. As such, the government takes claims seriously and punished accordingly.
Federal Medicare Fraud
Medicare Fraud is made illegal under federal statute 18 U.S.C. § 1347, the Health Care Fraud statute.
Under this statute, any person can be held liable for defrauding any healthcare benefit program or using false statements to obtain funds that are in the possession of any healthcare benefit program.
Medicare fraud can take many forms. Two common examples include a health professional who may charge Medicare for medical services that were not actually performed or a supplier of health care goods who may forge a prescription and charge Medicare for the cost of goods that were never purchased or needed.
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New York State Medicare Fraud
New York state criminalizes Medicare fraud under §§170.00 – 170.25 of New York Penal Law. Just as in federal law, this statute criminalizes fraud against any health plan.
There are 5 different degrees of health care fraud under New York State law, each carrying a penalty of different severity.
Health care fraud in the fifth degree (§177.05) is defined as any person or entity that, with the intent to defraud, willingly provides false information or omits necessary information in order to get a payment from a health plan for an item or service. In addition, as a result of the false information, that person, or another, receives payment in an amount they are not entitled to.
Under §177.05, there is no minimum amount that needs to be received in order to be found guilty. This is a class “A” misdemeanor.
Health care fraud in the fourth degree (§177.10) has the same definition of health care fraud in the fifth degree but with the addition that, in a single year, from a single health plan, the defendant must have received either as in payments or in portions of the insurance payout, more than $3,000. This is a class “E” felony.
Health care fraud in the third degree (§177.15) has the same definition of health care fraud in the fifth degree but with the addition that, in a single year, from a single health plan, the defendant must have received either as in payments or in portions of the insurance payout, more than $10,000. This is a class “D” felony.
Health care fraud in the second degree (§177.20) also has the same definition of health care fraud in the fifth degree but with the addition that, in a single year, from a single health plan, the defendant must have received either as in payments or in portions of the insurance payout, more than $50,000. This is a class “C” felony.
Health care fraud in the first degree (§177.25) has the same definition of health care fraud in the fifth degree but with the addition that, in a single year, from a single health plan, the defendant must have received either as in payments or in portions of the insurance payout, more than $1,000,000 ($1 million). This is a class “B” felony.
Investigations of Medicare Fraud
Typically, allegations of Medicare fraud are investigated by several different federal agencies.
These agencies include, but are not limited to:
- Federal Bureau of Investigation (FBI);
- Department of Justice (DOJ); and
- United States Department of Health and Human Services – Office of Inspector General (HHS-OIG)
Allegations of Federal Medicare fraud are serious and carry with them hefty penalties, discussed below.
If you have been charged with federal Medicare fraud, or if you are under investigation due to allegations of Medicare fraud, contact an experienced white collar criminal attorney today to ensure your rights and interests are adequately protected.
Potential Penalties if Convicted of Medicare Fraud
If you have been charged with, and are ultimately convicted with federal Medicare fraud, you may face up to 10 years in prison, a fine, or a combination of a fine and a prison sentence.
The fine for federal Medicare fraud ranges widely. A judge may choose to fine an individual $250,000 or an organization $500,000. A judge may also choose to fine, if there was any pecuniary gain from the offense, up twice the amount of the gain from the crime.
This means that if, as a result of your role in a Medicare fraud scheme, you received $500,000 the judge may fine you as much as $1 million.
New York State
Generally, in New York state, those convicted of health care fraud face a term of probation. While probation may seem less harsh than jail time, it has its own set of consequences. The most important being that if you are ever arrested for a crime during your probation period, you may be held in jail without bail or bond and you will regularly have to check in with a probation officer.
Simply because the offense carried no jail time does not mean that it can be taken any less seriously than those crimes that carry jail sentences as a potential punishment.
If you have been charged with, or are under investigation for, health care fraud in New York state you should contact an attorney as soon as possible.
- 5th Degree: In New York state, if you are charged with, and ultimately found guilty of health care fraud in the fifth degree, a class “A” misdemeanor, you face the possibility of a sentence from 15 days to up to a year in prison, a fine of either $1,000 or up to twice what was gained from commission of the crime, or a combination of both.
- 4th Degree: If you are charged with, and ultimately found guilty of health care fraud in the fourth degree, a class “E” non-violent felony, you face a sentence of probation for up to 1 ⅓ to 4 years. If you have a prior criminal history, this punishment may be harsher.
- 3rd Degree: If you are charged with, and ultimately found guilty of health care fraud in the third degree, a class “D” non-violent felony, you face the possibility of a sentence of a maximum of 7 years on probation.
- 2nd Degree: If you are charged with, and ultimately found guilty of health care fraud in the second degree, a class “C” non-violent felony, you face the possibility of a sentence of a maximum of 15 years on probation.
- 1st Degree: If you are charged with, and ultimately found guilty of health care fraud in the first degree, a class “B” non-violent felony, you face the possibility of a sentence of a maximum of 25 years on probation.
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A felony conviction has several additional consequences outside of jail time, probation, and fines. The possible consequences include:
- Potential loss of future employment opportunities due to background check requirements
- Delay in getting or denial of future applications for state licenses
- Loss of driver’s license
- Loss of the ability to vote and serve on a jury
- Loss of the ability to purchase a firearm
- Prohibition from running for or holding public office
- Ineligibility to enlist in the armed services
- Ineligibility for government aid
In addition to criminal charges, you may also be subject to civil cases and penalties because the allegations of Medicare fraud.
Possible Defenses to Charges of Medicare Fraud
If you have been charged with Medicare fraud, there are several defenses that may be used in order to fight for your interests.
The following defenses are generalized and are not guaranteed to get a successful result in every trial. Every accusation of Medicare fraud is different, so the defenses used need to be different as well.
If you have been charged with, or are under investigation for Medicare fraud, contact an attorney to ensure that your defense is tailored to your individual case and that you receive the best result possible.
Lack of Knowledge/ Intent
Two key parts of the crime of Medicare fraud statute is that the defendant must have acted with the intention to defraud AND knew of the mistake of fact. The burden of proving these facts is on the prosecutor.
If you, as a medical professional, mistakenly billed Medicare for a service that was not provided to a patient you cannot be found guilty of having committed Medicare fraud.
Whenever someone is brought up on criminal charges, the burden is on the prosecution to provide enough evidence so that a jury may find someone is guilty of a crime “beyond a reasonable doubt.” Medicare fraud cases are no different.
If the prosecutor lacks the sufficient amount of evidence to prove that you have committed Medicare fraud, the jury will be likely not to convict you.
If there is insufficient evidence, the judge may also, based on a motion from defense counsel, dismiss the case in its entirety.
New York State Affirmative Defense
In addition, New York state provides a potential affirmative defense under §177.30. An affirmative defense means that the defendant has the burden of proving what they claim is true.
This affirmative defense states that any person who is not an employee charged with active management and control, does not serve in an executive capacity and received no personal benefit can claim that they were merely following the orders of a superior employee who is authorized to control the defendant’s work-related activities.
In even simpler terms, this means that any person who was simply following directions from their boss and received no financial gain, may be found not guilty of any wrongdoing in the case of Medicare fraud.
Medicare Fraud Cases in the News
Medicare Fraud is a relatively rampant crime committed throughout the United States.
The following are recent, real allegations and convictions of Medicare Fraud and the punishments received by those convicted.
Houston Area Psychiatrist Convicted of Health Care Fraud for Role in $158 Million Medicare Fraud Scheme
Riaz Mazcuri was convicted on May 23, 2017, of one count of conspiracy to commit health care fraud and five counts of health care fraud. He was sentenced to 150 months (about 12 1/2 years) in prison and to pay back $20,607,410.22 to Medicare on September 4, 2018.
Mazcuri was involved in a Medicare fraud scheme that spanned a 6-year timeline. Mazcuri and his conspirators spent those six years defrauding Medicare by submitting to Medicare approximately $158 million in fraudulent claims for partial hospitalization programs (PHP) services through Riverside General Hospital.
Riverside General Hospital and Mazcuri paid bribes and kickbacks to employees at nursing homes and group homes to send patients with Medicare to the hospital.
Mazcuri indiscriminately admitted and readmitted patients into intensive psychiatric programs – often for years on end. Many of the patients suffered from severe Alzheimer’s or dementia and were unable to participate in the treatment purportedly provided at the PHPs, and who therefore did not qualify for the services.
Mazcuri rarely saw patients and would check in at the PHPs every so often to sign off on files.
Mazcuri was personally responsible for $4.5 million in funds received from the fraudulent billing. In addition, his signature on some of the files allowed for the hospital to bill for a total of $55 million out of the purported $158 million fraudulently gained.
For the full Department of Justice press releases on Mazcuri, click this link for his conviction and this link for his sentencing.
Medicare Fraud Strike Force Charges 91 Individuals for Approximately $430 Million in False Billing
Medicare Strike Force is a multi-agency unit run by the Department for Health and Human Services and includes the FBI and local law enforcement agencies.
On October 2012 the strike force arrested 91 people in seven cities, these people included doctors, nurses, and other licensed medical professionals.
Together, the indictments charge more than $230 million in home health care fraud; more than $100 million in mental health care fraud and more than $49 million in ambulance transportation fraud; and millions more in other frauds.
The defendants that were arrested allegedly participated in several different schemes to submit fraudulent claims to Medicare. These claims were submitted for treatments that were medically unnecessary and oftentimes never provided.
For the full Department of Justice press release on this matter, including a breakdown of the number of arrests per city, click this link or copy the below URL.
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Our attorneys are experienced, well respected federal litigators with expansive knowledge in all federal judicial practices and procedures.
Just as we have protected both private individuals and public companies in the past, we will strive to protect you, your family and your rights from charges and accusations of Medicare fraud.