San Francisco Health Care Lawyers Serving all of California
The health care industry is one of the most heavily regulated 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 Francisco 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
Contract Disputes
Criminal Defense
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Free Confidential Case ReviewCalifornia Penal Code 550
Under California Penal Code 550 it is illegal to knowingly present, or cause to be presented false or fraudulent claims aimed to claim a payment from an insurance company. California Penal Code 550(a) prohibits most forms of healthcare and medical billing fraud through its 10 different subsections.
If the allegedly fraudulent claims are worth less than $950 total, then the offense is a misdemeanor. In this case, the potential penalties are imprisonment for no more than 6 months, a fine if not more than $1,000, or both.
But if the claims total more than $950, the offense could be charged as either a misdemeanor or a felony. This charging decision is left to the San Francisco District Attorney in charge of the case.
If it is charged as a felony, the maximum penalties include fines of up to $50,000 or double the amount of the fraud, or a prison sentence of between 2 to 5 years, or both a fine and a prison sentence.
Federal Healthcare Fraud Laws
There are several statutes in the United States that make up what is commonly known as healthcare fraud. Each statute focuses on different actions and each action carries a different set of possible penalties if convicted.
Reaching out to an attorney to have them guide you through the complexities of the law will ensure you do not get caught up in the insignificant details.
Criminal Healthcare Fraud
(18 U.S.C. §1347)
This is aimed to punish, criminally, those who knowingly and willfully execute, or attempt to execute, anything that would defraud a healthcare benefit program of any money or other property under that program’s control.
If you are found guilty of criminal healthcare fraud, you could face up to 10 years in prison and up to 20 years if someone dies as a result of the misconduct.
Additionally, you may face fines of up to double the amount of the property you received as a result of the fraudulent scheme.
This is the only statute that deals with fraud in a criminal manner, i.e. the only one that carries a penalty of jail time.
The rest of the statutes below deal with the many ways you could be held monetarily liable for actions that constitute healthcare fraud.
The False Claims Act
(31 U.S.C., Chp. 37)
This statute is used to prosecute, civilly, those professionals in occupational therapy offices who purposefully submit fraudulent or false claims to insurance companies in order to receive a payment.
For example, if an in-home healthcare service bills a patient’s insurance company for in-home services that were never actually provided to that patient, that service may be charged with fraud under the False Claims Act.
If you are found guilty of a violation of the False Claims Act, you could face a fine of between $5,000 to $10,000.
In addition, you can be ordered to pay up to 3 times the amount that the government lost as a result of the scheme.
The Anti-Kickback Statute
(42 U.S.C. § 1320a-7b(b))
This statute looks to punish the purposeful payment made in order to reward people or companies for patient referrals. This can also include business transactions involving any item or service payable by the federal healthcare programs, including Medicare and Medicaid.
For example, if an oncologist pays a dermatologist to refer, specifically, patients with Medicare to come to the surgeon’s office. This would be a violation of the Anti-Kickback Statute.
If you are found guilty of violating the Anti-Kickback statute you could face fines of up to $25,000, a prison sentence of up to 5 years, or a combination of both.
The Physician Self-Referral Law (Stark Law)
(42 U.S.C. § 1395nn)
The Stark Law is aimed at punishing those doctors who refer patients to receive specialized medical care from any facility or business that the doctor, or any member of the doctor’s immediate family, has financial interest in.
For example, a general practitioner, after seeing a patient, recommends that they need some type of imaging service, like a CAT scan and refers them to an imaging center. If the physician refers the patient to an imaging center that the physician’s daughter owns, that referral would be a violation of the Stark law.
Another statute that could be considered healthcare fraud includes the Exclusion Statute (42 U.S.C. § 1320a-7).
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Free Confidential Case ReviewSan Francisco Healthcare Fraud Cases in the News
Three Defendants Sentenced to Prison in $3.2M Medicare Fraud Scheme
In June 2014, three people were sentenced for their role in a healthcare fraud scheme in the San Francisco Bay area.
One man was sentenced to almost 12 years. Another was was sentenced to about 4.5 years and the third was sentenced to 12 months and 1 day.
The three defendants were involved in a healthcare fraud scheme that used their San Francisco area medical distribution company to defraud Medicare by billing for medical equipment that was unnecessary.
The scheme began in 2006, when the medical distribution company began working with a doctor and street level recruiters. They would target Medicare beneficiaries and the doctor would write fraudulent prescriptions stating that those beneficiaries needed expensive power wheelchairs.
In 2008 one of the defendants began billing for these same claims under a different company name due to the scrutiny the first company was facing from Medicare because of the suspicious claims.
For the doctors participation in the scheme, she would receive anywhere from $50 – $100 in kickbacks for each patient.
Two of the defendants were also ordered by the court to pay restitution to both the United States and Medicare in amounts totaling around $3 Million each.
For more information or the full Department of Justice (DOJ) press release, click this link or copy and paste the following URL.
https://www.justice.gov/usao-ndca/pr/three-defendants-sentenced-prison-32m-medicare-fraud-scheme
Dignity Health Agrees to Pay $37 Million to Settle False Claims Act Allegations
In October 2014, Dignity Health, a hospital conglomerate, agreed to pay the government $37 million to settle claims that it violated the false claims act.
The government alleged that 13 Dignity Health hospitals submitted false claims to various federal health benefit programs by admitting patients who could have been treated on an outpatient basis.
Treating patients on an outpatient basis is less costly than admitting patients and treating them.
Additionally, the government alleged that for about 8 years, 4 of the 13 hospitals billed Medicare for beneficiaries undergoing elective procedures that should not have been billed to Medicare.
Further, the government alleged that for about 4 years, 13 hospitals admitted patients for certain common medical diagnoses where admission was medically unnecessary and appropriate care could have been provided through the less costly outpatient or observation settings.
Dignity Health agreed to implement an integrity agreement which requires the company to engage in compliance efforts for 5 years and must retain independent review into the accuracy.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
The United States Settles False Claims Act Case with Nursing Home Company to Settle Allegations of Medically Unnecessary Rehabilitation Therapy Services
In September 2016, North American Healthcare, Inc. (NAHC), agreed to pay a total of $30 million to resolve allegations that they violated the false claims act.
The government alleged that NAHC submitted claims to government healthcare programs for medically unnecessary rehabilitation therapy services they performed.
In addition to the monetary settlement, NAHC agreed to comply with an integrity agreement which applies to all facilities managed by NAHC. The agreement mandates that NAHC has an independent review organization review its therapy services billed to Medicare annually.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
Pharmaceutical Companies Ordered to Pay $67 Million to Resolve False Claims Act Allegations Relating to Tarceva
In June 2016, Genentech, Inc., which is headquartered in San Francisco, and OSI Pharmaceuticals, LLC agreed to pay $67 million to resolve allegations that it violated the False Claims Act.
The government alleged that the two companies made misleading statements about the effectiveness of the drug Tarceva, which was to be used to treat non-small cell lung cancer.
Further, it was alleged that between 2006 and 2011, the companies made misleading marketing presentations to healthcare providers, particularly physicians, about the effectiveness of Tarceva.
This included statements that the drug worked in certain patients when there was little to no evidence that this was true.
As a result of the settlement, the federal government will receive over $60 million dollars and the Medicaid program will receive $4.4 million dollars.
For more information or the full DOJ press release, click this link or copy and paste the following URL.
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Free Confidential Case ReviewWoman Arraigned on Insurance Fraud Claims
In March 2011, Emily K. Hegner was charged with insurance fraud in San Francisco.
It was alleged that Hegner, who worked for the San Francisco Department of Health under a different name, made false statements and omitted material information from her reports to her doctors about her medical condition and physical abilities.
Specifically, Hegner claimed that while she was working, she injured her lower back, left hip and right wrist.
During the course of her medical evaluations and treatment, from July 2007 to September 2010, she reported pain and difficulty in walking distances. She also claimed that, due to her injuries, she could no longer walk alone and that she now required assistance walking.
Unfortunately for Henger, the prosecution was able to obtain evidence that, on April 12, 2008, Henger entered and completed the seven mile Muir Woods Marathon.
Six days later, when Hegner visited her physician using her cane and requested a handicap placard, she failed to disclose to her doctor that she had run in the race.
Hegner faces up to 9 years and 8 months in prison as well as restitution.
For more information or for the full San Francisco District Attorney press release, click this link or copy and paste the following URL.
https://sfdistrictattorney.org/woman-arraigned-insurance-fraud-charges