San Diego Healthcare Attorneys Serving al of California
The health care industry is one of the most heavily industries with numerous State and Federal agencies providing oversight. As such it has become critically important that practitioners, professionals and healthcare executives have legal counsel experienced in matters related to the health care industry.The attorneys at the Health Law Group can help identify any potential risks, negotiate corporate transactions and to provide strategic representation and advocacy in complex litigations and potential criminal proceedings.
With experience in all aspects of healthcare law, the attorneys at the Health Law Group represent client interests in a wide array of litigation, regulatory, employment and criminal related matters. Our lawyers have helped many clients resolve some of the most complex legal issues including corporate structure, merger and acquisitions, government regulations and state and federal fraud abuse matters.
Our San diego lawyers provide legal counsel to healthcare providers including hospitals, physicians, treatment centers, clinics, dental offices and more. We understand the unique challenges that pharmaceutical manufacturers and durable medical equipment manufacturers face. Our healthcare lawyers can assist advise you on a number of legal issues including but not limited to:
Internal audits and investigations
Medi-Cal Fraud and other Health Care Fraud issues
There are many different reasons that you could be accused of healthcare fraud while working as a provider in San Diego.
Healthcare Fraud Statutes That Apply To San Diego Healthcare Providers
Anti-Kickback 42 U.S.C. 1320a-7b(b)
As a healthcare provider in San Diego, the business deals and referrals that you make are regulated by federal statutes and some state statutes. Depending on your financial relationship with another person, a referral could be illegal. This violation would stem from you making a referral to another person, either in San Diego or in some other location, with whom you have a financial relationship. This statute applies to both making a referral for the receipt of money and paying money for a referral.
The elements of anti-kickback include that you purposefully solicited or received any form of payment in exchange for the arrangement services (including goods and equipment) that are part of a federal program or exchanging a referral of a patient.
Penalties For Anti-Kickback
As a provider in San Diego, if you are found guilty of the anti-kickback statute, you will face a prison term of up to 5 years. There is also a fine of up to $25,000 that could apply. In many cases, you could be both fined and given a prison sentence.
Healthcare Fraud 18 U.S.C. § 1347
Being a provider in San Diego, accusations can stem from suspicious behavior like falsely making a claim for a benefit or good without providing any services.
To prove that the allegations for healthcare fraud are true, your accuser must prove that you:
- purposely and voluntarily,
Either succeed or attempt to defraud a healthcare benefits program
And that your fraudulent act was to obtain a benefit from the healthcare program.
Penalties For Healthcare Fraud
Healthcare fraud can cause you to face a range of penalties. For example, in instances of guilt to fraud, you could possibly serve a prison term of up to ten years. Additionally, there is a fine that you could have to pay. In many instances, you could be penalized with both. However, this limit can be enhanced to 20 years in the event that you cause any of your patients to suffer injuries that are directly related to your healthcare fraud, and those injuries resulted in serious bodily injury or death.
False statements relating to healthcare matters 18 U.S.C. § 1035
The types of statements that you make in relation to your healthcare services as a San Diego provider are also regulated. 18 U.S.C. § 1035 requires that these statements be true. Generally, this statute focuses on the entries that you make in relation to healthcare benefits programs. These entries could be on patient information sheets, prescriptions, and even claims. The statute will look at whether you falsified any material fact or made any fraudulent entries in relation with the delivery or payment of a healthcare benefit.
Penalties For False statements relating to healthcare matters 18 U.S.C. § 1035
In the instance that you have violated 18 U.S.C. § 1035, you will be subject to criminal penalties. These criminal penalties could be either a term or imprisonment of up to five years, a fine, or both.
If you are a healthcare provider in San Diego, your practice can also be subject to civil lawsuits alongside criminal charges.
False Claims Act – 31 U.S.C 3729-3733
The False Claims Act is the civil statute that applies to your San Diego healthcare practice and is related to the criminal healthcare fraud statute. As a healthcare provider in San Diego, if you are sued for the false claims act this will be a civil action against you for giving services that you did not actually provide, or for providing unnecessary services.
Penalties For Violating The False Claims Act
If your San Diego healthcare practice is found to have violated the False Claims Act, there will be penalties. Generally, the penalties will be in the form of a fine ranging from $5,000 to $10,000. Regardless of this range, you can have multiple cases of fraud which would mean multiple fines with this range. This fine is not the only fee that you will pay as restitution is often ordered. The amount of restitution will depend on the specific damages that your practice has caused.
Physician Self-Referral / Stark Law – 42 U.S.C. 1395nn
Like the criminal Anti-Kickback statute, there is also a civil prohibition on your San Diego healthcare practice making certain referrals. The statute is called The Stark law. Essentially this law prohibits San Diego healthcare providers from referring patients to other healthcare providers or individuals with whom you are closely related either by blood or financially.
The Stark Law comes with four types of sanctions: 1) monetary penalty for the improper claims, 2) denial of payment, 3) Civil monetary penalty for helping with a referral scheme, and 4) refunding payments.
Monetary penalty for the improper claims – If your San Diego healthcare practice presents a claim for services and you have knowledge that the claim should not be made, you could face a penalty of up to $15,000. This statute applies to claims submitted to both the government and private citizens.
Civil monetary penalty for helping with a referral scheme – Generally helping with a referral scheme will result in a significant penalty. This is because the statute looks at all the different times that you are alleged to have made an arrangement. The statute will calculate each and every violation and order a civil monetary of up to $100,000 for each violation.
Defenses to Allegations of Healthcare Fraud San Diego Healthcare Providers
In the event you are accused of healthcare fraud, any and all of the statutes can apply. This means the penalties you face will likely be severe. It is necessary for you and your practice to have a defense to fight your healthcare fraud case and doing this alone will be difficult. Having an experienced and skilled defense attorney can help you find your best defense.
Generally, most fraud cases the key element is that your accusers must prove that you had the required state of mind to defraud. Working with an experienced healthcare attorney will help you to look back at your facts and determine what was going on. It could be that your acts had not fraudulent intent in them at all.
Generally, the most important element of a crime to fight is the state of mind requirement. Most often, but not always, in healthcare fraud, you must have purposely committed a fraudulent act. However, you know the true facts of your case, and you know why you did what you did. It could be that your acts had no fraudulent intent at all. Rather, you made assessments based on your training.
Of the many federal statutes and regulations around medical care, a major focus has been on healthcare fraud. In response to the rising cases of abuse, agencies changed the way they investigated providers involved in fraudulent behavior by creating special task forces.
The Healthcare Fraud Task Force was created to continuously audit providers and the submissions that they make.
Your daily tasks and responsibilities as a provider are regulated by these federal regulations and agencies. Almost all of the documentation you make as a provider can be reviewed and audited by the government for concerns of fraud, waste, or abuse. You could find yourself being investigated for failing to appropriately charge for services, falsely determining which services need to be provided to a particular patient, and even making referrals to other healthcare providers.
Regardless of how you conduct your practice, mistakes can result in serious allegations. Unlike other areas of law, healthcare fraud usually results in both criminal and civil allegations on a federal level and state level. This means you can be charged in California and on a federal level as well. These cases can be pursued at the same or a different time. Unfortunately, a resolution in one often does not mean a resolution in the other.
Our law firm has a healthcare group made up of experienced attorneys who have successfully represented clients throughout the country. Please contact our office to be put in touch with a healthcare attorney for a free review of your case.
San Diego Healthcare Fraud In The News
Group Of San Diego Ambulance Companies Pay Millions For Kickback Allegation
In 2014, a lawsuit was filed against five San Diego area ambulance companies for their roles in a large kickback scheme.
As part of this scheme, the ambulance companies would give discounted prices to certain hospitals and nursing facilities. In exchange for the discounted prices, the five ambulance providers would get exclusive rights to Medicare patients that the discounted facilities were treating.
The reason for the exclusivity of these rights is because Medicare patients get more profitable benefits and return pay. In this case, the ambulance providers were making large amounts of money because the patients were covered under the Medicare program. Therefore, receiving more money even after they were already discounting their prices that they charged the hospitals and facilities.
In the end, in order to settle the claims against them, these San Diego ambulance companies agreed to pay more than $11.5 million.
San Diego Based Healthcare System Resolved to Healthcare Fraud Allegations by Agreeing to $1.5 Million Restitution Amount
In early 2018, Scripps Health settled their case for allegedly violating the False Claims Act. They agreed to pay the government $1.5 million in restitution for making claims by falsifying the what providers were providing services.
The allegations against Scripps Health revolved around the type of care that Scripps Health was claiming they provided to patients. More specifically, they were claiming part of their practice was covered by Medicare and TRICARE.
You must be an authorized provider in order to provide healthcare treatment and receive benefits from a government program for those specific treatments. If you are not an authorized provider, you must be supervised by an authorized provider to claim a benefit.
While Scripps Health is an authorized program, they sometimes needed to contract with a therapist who could provide specialized services. The contracted therapist was not an authorized provider and did not have billing privileges with the Medicare and TRICARE programs. Regardless of this lack of authorization, Scripps Health still made benefit claims to the healthcare programs for the services provided.
An unauthorized provider may provide care and it could be submitted for benefits. The supervision requirement is more than being under the roof of an authorized provider. Supervision means that the authorized provider must be directly supervising the unauthorized user. The main issue in this case was not just that the therapist was providing the care but that Scripps Health failed to provide sufficient supervision.
Because of the lack of supervision, a civil lawsuit was brought against Scripps Health. In the end, Scripps Health agreed to pay $1.5 million in restitution.
San Diego Drug and Genetic Testing Scheme Results in $256 Million Fine
In 2015, after a civil lawsuit settlement agreement, the allegations against Millennium Health for healthcare fraud are brought to an end.
Millennium Health is alleged to have entered into multiple agreements with San Diego area healthcare providers to exclusively refer patients to their company for drug testing services. As part of this agreement, the complaint by the United States government alleged that the tests that were prescribed were either excessive and/or unnecessary during the dates of 2008 to 2015.
Due to the scheme between Millennium Health and these providers, patients were not being assessed for the appropriate services they needed. Rather, these providers only focused on the payment they would be receiving from Millennium Health and submitted as many drug tests as possible.
First, the agreement for referrals in exchange for payment was an alleged violation of the Stark Law and the Anti-Kickback Statute. Second, the additional and unnecessary tests that were conducted on the patient specimens were alleged violations of the False Claims Act.
In the end, Millenium Health settled and agreed to pay $256 million for the multiple violations they were charged with.
San Diego Pharmaceutical Company Pays Large Fee To Settle Healthcare Fraud Allegations
In order to resolve their federal cases, both civil and criminal, Victory Pharma agrees to settle in the amount of $11,420,743. The allegations against Victory Pharma Inc. revolved around the promotion of prescription drugs and how they influenced doctors to promote and prescribe them. Specifically, Victory Pharma Inc. was paying doctors kickbacks for prescribing the drugs.
The federal government further alleged these payments and kickbacks came in the form of tickets to sporting events, concerts, and plays. The payments also included gift certificates to spas, golf courses, ski reports. Essentially Victory Pharma Inc. used any form of payment to encourage healthcare providers to prescribe their medications.
Even more aggressive than these payments, were the steps that Victory Pharma Inc., took to ensure these drugs were being prescribed. Victory Pharma paid sales representatives to go to the providers office and job shadow the providers. Essentially influencing them from the inside and forcing them to prescribe Victory Pharma medications.
In the end, the San Diego based pharmaceutical company paid $11.4 million to settle these healthcare fraud claims.
San Diego Affiliated Medical Device Manufacture Accused of Selling Unreliable Products Settles Claims
In early 2018, a medical device company based out of Massachusetts with a San Diego Subsidiary (Alere), settles claims against the company for knowingly manufacturing products that are unreliable and selling them to healthcare companies.
The allegation of this case surrounds a period of six years dating from 2006 to 2012. The federal government alleged that the San Diego company knew the products they were selling were unreliable but continued to sell them. The purpose of these products was to aid in the diagnosis of heart failure, acute coronary syndromes, drug overdose, and other conditions.
The products were considered significant as they are critical to ensuring proper patient safety, care, and life support. Regardless of the many complaints the San Diego company received about erroneous results, they ignored the complaints and did not take any corrective actions.
This case falls under federal action because the patients receiving treatment with the products being used were covered by Medicaid, Medicare and other federal healthcare programs.
Because of the number of issues that these products caused and the period of time that this occurred, the San Diego medical device manufacturer agreed to pay $33.2 million in order to settle the healthcare fraud claims.
What To Do If You Are Accused Of Healthcare in San Diego
If you are accused of healthcare fraud in San Diego, you will need to act fast. Being accused can result in some unforeseen penalties without a finding that you actually committed fraud. This includes loss of licensures and certifications, and even the loss of your job. A quick reaction and defense team can help minimize or eliminate these things from happening.
In the long run, you should be taking proactive steps to avoid allegations. If you are accused, review your practice and compare it to the allegations against you. Try to pinpoint the practices that have caused the allegations in order to discontinue that act or practice.
Finally, contact a defense attorney as soon as you can. Our law firm has experienced healthcare fraud attorneys who can review your case and help you to make the appropriate steps in defending your case.