Medical Billing Fraud
Our Health Law Group has vigorously defended clients charged with crimes related to health care fraud and medical billing fraud.
If you or your business is under investigation for medical billing fraud, you should contact an attorney immediately. An experienced attorney can work with the investigators and you to help resolve any problems and defend you against any claims of fraud.
What is “Medical Billing Fraud?”
Under the umbrella of health care fraud falls the more specific crime of medical billing fraud.
Medical billing fraud involves a medical professional’s misrepresentation of information on any billing records for medical purposes. Medical professionals in the field need to be careful with their practices to avoid any liability for this kind of fraud.
Medical billing fraud may have both criminal and civil penalties.
Common Medical Billing Fraud Practices
Some common practices that fall under medical billing fraud include double billing, billing for services not needed, upcoding services or the most common billing for services that were never rendered. All of these acts involve fraudulently misrepresenting information on medical billing, usually involving attempts to make more money.
Federal Medical Billing Fraud Statutes
18 U.S.C. § 1347 and the False Claims Act are the two primary federal laws under which you may find criminal and civil liability. You may also be charged with a variety of federal fraud, theft and perjury statutes as well. However, the main crimes are health care fraud 1347 and the False Claims Act.
- Health Care Fraud. 18 U.S.C. § 1347 is the main criminal statute that the federal government would prosecute a case of medical billing fraud. Medical billing fraud is only one of the type of act that the Health Care Fraud covers. To be found guilty under this law you need to defraud a health insurance provider or fraudulently obtain funds from an insurance provider. If you are found guilty under the Health Care Fraud statute, you may face up to 10 years imprisonment for each instance of fraud the prosecutors can prove. To prove this crime, they need to show fraud and prove that the fraud was intentional.
- False Claims Act. The False Claims Act is also one of the federal government’s most effective tools to combat fraud in the practice of medicine. 31 U.S. Code § 3729 the False Claims Act imposes several civil penalties for payments made through public insurances like Medicare and Medicaid. An instance of medical billing fraud could fall under this statute and impose civil penalties.
- Civil Punishments. The civil punishment for a violation of the false claims act includes a civil penalty and reimbursement for any payments the government made through your fraudulent act. If you fraudulently bill the federal or any state insurance, you may be held liable to pay back all payments made. The civil penalties under this act may become quite extensive.
Medical Billing Fraud in New York
In New York, the act of medical billing fraud is convicted under New York Penal Law Article 177 Health Care Fraud. There is also a chance that if you are committing an act of medical billing fraud that you are also committing several other crimes involving theft, fraud, and perjury.
Article 177 Health Care Fraud involves the act of providing information to any health plan with information that you know is false for the purpose of getting payments.
This means if you are altering medical bills to get more payments you might get prosecuted under this statute in New York. This crime is also broken down into degrees as follows;
- Fifth degree involves fraud for any amount and is a class A misdemeanor.
- Fourth degree involves fraud for an amount over $3,000 and is a class E felony.
- Third degree involves fraud for an amount over $10,000 and is a class D felony.
- Second degree involves fraud for an amount over $50,000 and is a class C felony.
- First degree involves fraud for an amount over $1,000,000 and is a class B felony.
Detection and Investigation
The act of medical billing fraud is usually found through investigation by either the state or the federal government. Cases are usually brought to the attention of the authorities by patients who report problems with their billing.
- The Department of Justice (“DOJ”). The DOJ has a dedicated Health Care Fraud Unit that specifically works on investigations of fraud in the health care industry including medical billing fraud. When there is a suspected case of medical billing fraud, this unit would usually investigate for the federal government.
- Attorneys General’s Offices. The New York Attorneys General’s Office has also dedicated a unit to combating fraud known as the Medicaid Fraud Control Unit. In addition to the dedicated units for health care fraud there are also investigators for insurance companies and each agency usually does some of its own auditings.
If you are under investigation for medical billing fraud, it is important to contact a lawyer with experience in dealing with these charges. The investigation process and charges of billing related fraud can get quite complicated so an experienced attorney will provide to be very useful.
May I Have An Attorney Present During Questioning?
It is important to know your rights if you are under investigation. During an investigation, you may retain an attorney and that attorney may be present for all questioning.
If you are questioned by the authorities, you must maintain the right to remain silent, the right not to incriminate yourself, and your right to speak to an attorney.
During an investigation, your lawyer will be able to work with the various government agencies in dealing with the potential charges. The fact that you are under investigation may not mean that you will get charged for medical billing fraud. The best chance you have to defeat any suspicion during an investigation is to hire an attorney with experience in dealing with these specific types of cases.
Defending Against Charges of Medical Billing Fraud
An investigation into medical billing fraud could result from a simple mistake of your own, or a mistake from your employee. Understanding what happened and what the authorities are searching for is important in any case of medical billing fraud.
A Health Law Group attorney would help sort out any discrepancies and work with the authorities to help remedy or explain any potential problems.
When you commit medical billing fraud, you might get charged under multiple fraud statutes and even some theft statutes. Crimes that are overlapping or unfound may be able to be resolved or dropped with the help of an attorney. An attorney may also help you to negotiate any charges to be a lesser offense than the original crime.
A conviction of medical billing fraud could come with criminal fines and jail time and significant civil penalties.
It is important to understand if you are part of a medical business what the implications are against you personally as opposed to the group as a whole. For conviction of medical billing fraud, the prosecutor will need to show that you specifically were the one that committed the offense and that you did so knowingly. If there was a case of medical billing fraud, a possible defense would be that you did not knowingly commit the offense.
Medical Billing Fraud in the News
Health care fraud in the US is highly covered in the news and is also prosecuted with a high level of frequency including civil and criminal cases. While medical billing fraud is a smaller subset of the health care fraud, it still accounts for a large number of these types of cases.
- New York. In New York, a surgeon received a sentence of 13-years imprisonment for his acts of defrauding Medicare for close to $85 million for procedures he did not perform. The sentenced ordered by the Eastern District of New York judge was $7.3 million dollars in restitution, a $20,000 fine, and 13-year jail sentence. The surgeon would write up bills and submit them for procedures that never occurred over the course of a few years.
- Florida. The US Attorney General’s office recently settled a case in Florida for about half a million dollar settlement to Medicare. The case was opened due to two employee whistleblowers that reported the activities of Eye Centers of Florida. This case is important because the employees recognized a problem and reported to the authorities and now Eye Centers has to pay out $525,000 under the False Claims Act.
- Texas. In Fort Worth Texas, on October 3, 2018, two women were criminally charged for stealing close to 6 million dollars fraudulently. The two women were changing information on their billing to maximize the payments for each client seen by their clinic. One of the false claims was for physical therapy that never occurred. If you change bills and bill for services that never happened there, you may have committed medical billing fraud and may face potential jail time.
What If I Am Accused of Medical Billing Fraud?
To avoid liability for medical billing fraud, it is to keep accurate and detailed billing records. TAll levels of the medical profession from admin to the doctors need to make sure when they record any information for billing purposes.
Training all medical employees the proper method of entering all billing charges is important to avoid allegations of false billing.
An attorney with experience in medical billing fraud may be able to help you remedy any inaccurate information that has been reported in your billing. Working proactively to address this situation before it becomes a problem could be the difference between being charged or not.
While medical billing errors sometimes occur, the best course of action is to have a good plan in place to prevent future problems, address current problems, and to remedy any past problems.
The first thing you should do if you are under investigation for medical billing fraud should be speaking to a lawyer. If you are proactive and work with your attorney, you may be able to avoid charges or lessen the severity of any charges. Communication with the authorities could get tricky with complicated cases of medical billing fraud, and you do not want to accidentally incriminate yourself.
Call A Health Law Group Attorney Now
If you are under investigation or charged with medical billing fraud, it is important for you to contact an attorney to help defend you against these allegations.
Medical billing fraud can be a very serious charge and having a criminal attorney that specializes in federal criminal health care law can make all the difference.
Having an attorney that understands the intricacies of the law will help you plan the best course of action for you. An experienced attorney will plan the next steps and will be present during questioning to help you through the investigation process.
Your medical license, your money in penalties and your freedom are on the line if you are found to have knowingly altered medical billing records.