Legal Services for Acupuncture Clinics
The Health Law Group has represented acupuncture clinics in connection with all types of business transactions, government investigations, and criminal proceedings. Our attorneys are prepared to represent or defend you against any charges or issues you may be facing.
Providing Treatment for Unrelated Injuries
Most workplace insurance plans generally limit insurance coverage to treatment directly pertaining to injuries that occurred on the job. Providing acupuncture treatment for injuries that are not directly related to the injuries sustained while the patient was working may be considered fraudulent if you bill them as such.
For example, an acupuncture clinic continuously miseducated patients regarding what their policy covered in order to persuade the patient to consent to treatments for unrelated symptoms so that the clinic would be able to collect the reimbursement for those procedures. Claiming a treatment is necessary to healing an injury when in fact it is either unnecessary or unrelated to the injury is considered fraud.
Prosecution of Cases Involving Treatment for Unrelated Injuries
The practice of medicine is subjective, and conviction requires the prosecution to present enough proof to establish that you violated the relevant statute beyond a reasonable doubt.
Our criminal defense lawyers will explore all potential defenses in order to cast doubt on the assertion that you acted intentionally. Our criminal defense attorneys have the experience and knowledge necessary to understand all opportunities for defenses your case might present.
18 U.S. Code § 1347 – Federal Healthcare Fraud Statute
18 U.S. Code § 1347 makes it illegal to defraud a private insurance company or government insurance program and is punishable by fines, imprisonment, or both. Common Health Care Fraud Schemes can be committed by health care providers, insurance agencies, pharmaceutical companies, or patients. Regardless of the form, the deliberate false representation of information in a healthcare context is a criminal act.
If you are the owner of an acupuncture clinic, the actions of those within your facility, as well as the outside healthcare providers you work with, may expose you to liability for health care fraud. At the federal level, healthcare fraud is generally prosecuted under 18 U.S. Code § 1347.
Elements of the Federal Health Care Fraud Statute
The elements that the prosecution is required to prove in order to convict a defendant of health care fraud include the following:
The willful execution of a scheme to defraud a healthcare benefit program, or obtain by fraudulent pretenses, representations or promises, any money owned by or under the control of any healthcare benefit program.
Prosecutors may attempt to bring charges any time they believe your conduct meets the statutory elements required for conviction.
Penalties for Violating 18 U.S. Code § 1347
Penalties for violating 18 U.S. Code § 1347 include:
- Imprisonment up to 10 years; and
- Criminal fines up to $250,000.
It is important to note that penalties vary according to:
- whether the conduct is prosecuted under state or federal law;
- the scope of the fraudulent conduct;
- the harm caused;
- the length of time involved;
- the breadth of the fraudulent scheme; and
- your criminal history.
State Health Care Fraud Violations
Most states have their own version of this statute and carry similar penalties. However, it is important to note that the federal statute broadly prohibits the execution of a fraudulent scheme against any healthcare benefit program, not simply one under the control of the federal government (such as Medicare). This means that even if you do not commit fraud upon a federal healthcare program, you could still face federal charges.
Example – “New York’s Largest No-Fault Insurance Scheme”
In 2013 several acupuncture clinics were among 36 New York defendants indicted for a No-Fault Insurance scheme, which the Department of Justice termed the largest in New York’s history.
In New York, no-fault insurance covers up to $50,000 of car accident injury treatments regardless of fault. It also entitles victims to assign their rights to monetary damages, which might take years to obtain to the medical facilities that treat victims. This system allows victims to receive treatments they may not be able to immediately pay for when they need it.
However, rights can only be assigned to facilities that are incorporated, owned, operated, and/or controlled by a licensed medical practitioner. So in this case, the ineligible clinics paid licensed medical doctors to incorporate their businesses, in order to falsely represent themselves as eligible. The plan also included excessive and unnecessary referrals for medical treatment as well as the illegal receipt of kickbacks in connection with those recommendations.
If you are/have been involved in a similar scheme, know that the defense of a criminal firm with extensive healthcare fraud experience and an effort-based strategy is your best hope of mitigating the consequences you will face. We have represented clients involved in a wide variety of fraudulent schemes and have successfully obtained results they never dreamed possible.
31 U.S. Code § 3729 – False Claims Act
31 U.S. Code § 3729, also known as the federal “False Claims Act,” makes it illegal to file false records or make false claims to the government. Anytime false information is deliberately submitted to an insurance program, it is considered healthcare fraud punishable under state or federal law, and possibly both.
While the False Claims Act applies to claims submitted to the federal government, its reach is broader than it may initially appear because claims submitted to private insurance companies may subsequently be submitted to the federal government.
31 U.S. Code §§ 3729(a)(1)(A) and (B) provide the elements that the prosecution is required to prove in order to convict a defendant of submitting a false claim:
- whether the conduct is prosecuted under state or federal law;
- knowingly submits a false claim to the government;
- knowingly makes a false record or statement to get a false claim paid by the government.
Penalties for Violating the Federal False Claims Act
The criminal penalties for violating the federal False Claims Act include:
- A fine up to $250,000; and
- Up to five years in prison for each false claim submitted.
- $11,000 for each false claim; and
- Up to three times the damages to the government for the claim.
Our criminal defense attorneys will help you assess what laws govern your conduct and what types of penalties you will face.
State “False Claims” Violations
If your specific conduct does not fall under the federal False Claims Act, you will likely face similar penalties at the state level. It is important to note that each state has its own Medicaid program, with corresponding statutes criminalizing fraud committed on those programs.
Statutes prohibiting the submission of false claims cover a wide variety of conduct. It is important to understand that if you are an acupuncture clinic and you have submitted false information to any insurance plan, you have likely triggered the False Claims Act at the federal level or its equivalent in your state.
Most states have adopted some version of the False Claims Act along with the attendant whistleblower protections.
While acupuncture may not be covered by many insurance companies, it is often performed in the same facility as other treatment modalities, like physical therapy and chiropractic adjustments, which are generally eligible for insurance coverage.
This allows employees and operators of these clinics to fraudulently obtain reimbursements by claiming they are performing other services that are in fact covered by the applicable insurance plan.
For example, a medical center composed of two chiropractors, a physical therapist, and an acupuncturist conspired to commit healthcare fraud when they billed a range of uncovered treatments, including diagnostic tests, massages, and acupuncture treatments under the general label “physical therapy.”
In this case, only “physical therapy” was covered by the relevant insurance plans. The conspiracy resulted in over $30 million dollars in fraudulently obtained reimbursements.
Often, this form of fraud overlaps with:
- the submission of false claims;
- exaggerating the need for coverage;
- providing or recommending more services than the patient needs; and
- billing for services you never rendered.
What is “Medicare?”
“Medicare” is a federal program providing insurance to those 65 and over, as well as individuals with certain disabilities. Considering that Medicare strictly operates at the federal level, if you defraud this program it is a near guarantee that you will face federal charges, which are generally more severe and can come with stricter penalties than state charges.
What is “Medicaid?”
“Medicaid” is a similar program, the difference being that it operates at both federal and state levels. Each state has its own statutes criminalizing Medicaid fraud.
Medicare and Medicaid programs cover a limited number of conditions to a limited number of patients, but acupuncture clinics can commit Medicare/Medicaid fraud in numerous ways.
The impact of defrauding these programs weighs heavily on society because they provide expensive treatment modalities, prescriptions, diagnostic testing, procedures and other forms of potentially life-saving care to a large number of people.
Medicare and Medicaid coverage is funded by taxpayer dollars and provided to those who essentially cannot live without it. Accordingly, it is one of the most heavily prosecuted types of healthcare fraud carrying steep penalties.
What Statutes Apply?
A number of statutes can apply where Medicare fraud is committed, including:
- the False Claims Act;
- the Social Security Act;
- the Health Care Fraud Statute; and
- similarly adopted statutes at the state level.
One of many examples of Medicare fraud involving an acupuncture clinic occurred in 2014 when a licensed acupuncturist submitted claims for acupuncture treatments which were not properly rendered.
For example, the acupuncturist:
- billed for physical therapy and massage treatments that were not performed by licensed practitioners as required under Medicare;
- Billed for doctors visits that were not performed by a licensed physician.
Generally speaking, this type of fraud committed on Medicare/Medicaid is punishable by up to five years in prison for each false claim submitted, as well as fines.
What is “Double-Billing?”
“Double-Billing” is the act of billing services to more than one insurance plan in order to obtain double the reimbursement.
If an individual is injured on the job, their employer may provide coverage for their injuries. However, if that individual also has private insurance, or is covered by a government health plan, a clinic might bill both the employers insurance plan – as well as the private insurance plan of the individual – for the provided services. This would be considered double-billing, a practice which has been the focus of many federal health care fraud cases.
Prosecution of “Double- BIlling” Cases
While proof of healthcare fraud generally requires that the accused acted deliberately, evidence that the facility accepted reimbursement from both insurance plans can potentially provide enough evidence of intent that the prosecution must prove beyond a reasonable doubt in order to reach a conviction.
However, if you are in this position, it is important to understand that the representation of a quality criminal defense attorney can make all the difference in your case.
Having the proper defense can raise enough reasonable doubt in the minds of a jury to prevent a guilty verdict, and strategic lawyering from the start could lead the prosecution to offer a favorable plea deal or even drop all charges prior to trial.
Detection of Fraud in Acupuncture Clinics
If you are an acupuncture clinic that has engaged in any type of healthcare fraud, it is crucial to understand that even if you have not yet been faced with charges, there are numerous ways in which the government can uncover your conduct and impose criminal penalties.
As discussed above, the federal False Claims Act contains protections for whistleblowers who report fraud, as well as monetary incentives.
Whether it is a patient, colleague, employee or even co-conspirator, the structure of the statute is deliberately set up to incentivize the reporting of fraudulent activity.
Think No One Knows?
Even if you are the only person aware of your fraud, and even if you have been getting away with it for years, a combination of technological advancements, increased vigilance regarding fraudulent patterns, and rising government focus on eliminating healthcare fraud make it almost impossible for your scheme to continue without detection.
Our Health Law Group is prepared to provide you with the strictly confidential counsel you need to prepare yourself for questioning and protect yourself from inadvertently sacrificing your rights and opportunities.
The Health Law Group has years of experience combating healthcare fraud charges. We have successfully negotiated plea deals our clients never thought possible, and our track record includes an impressive number of acquittals and dismissals. You can count on us to provide you with the knowledge and experience you need behind you if you are under investigation.
We are available for a risk-free consultation to discuss your specific circumstance and situation and help you identify the best possible strategy you can employ to defend yourself.