Legal Services for Health Care Assistants and Employees
A successful medical practice consists of doctors, health care assistants, and various other non-medical employees, who share the work. Due to their access to patient, and billing information, health care assistants and employees often commit health care fraud.
Healthcare fraud is the knowing and willful use of wrong information or omitting information to defraud any health care benefit program, whether public or private. Charges of health care fraud are serious and carry with them lengthy prison sentences and hefty fines.
If you believe you or your business are vulnerable to charges of health care fraud, contact an attorney today to discuss possible preventative measures you can take and how to best prepare yourself for potential charges or an investigation of health care fraud.
Who is Considered a Health Care Assistant or Employee?
Any person providing care in a medical setting may be considered a medical assistant. This includes nursing assistants, support workers, and auxiliary nurses.
The assistants work under the direction of doctors, nurses, or physicians assistants. They spend a lot of time with patients and work to ensure the patient’s comfort and safety.
Health care employees or any member of the support staff in a medical setting. This could be anyone from a receptionist to a janitor. Most health care assistants and employees have access to the computers and billing systems and use them as an integral part of their job.
What is Health Care Fraud?
Health care fraud is illegal under 18 U.S.C. §1347. It is the provision of false information to an insurance provider to obtain money or other property from the provider.
The federal crime requires prosecutors to prove four elements to obtain a conviction for health care fraud. These elements are:
- Knowingly or willingly attempts to execute
What this means is that the defendant must knowingly provide false information, a simple mistake of fact would not suffice. The defendant must intend to falsify or omit information submitted to the insurance company. The provider uses it to send money or property in return.
An example of this would be of a receptionist who, at the direction of a doctor, submits a bill to a patient’s insurance company for a service that was not provided to the patient, and the receptionist did not know that the service was not provided.
Here, the receptionist would not have had the necessary intent and therefore could not be liable for the fraud that was committed.
2. A scheme or artifice
3. Through false or fraudulent means
Fraud deceives another to secure an unethical or illegal gain or to deny a victim of a legal right. Fraud differs from abuse of position as a medical professional or employee. Abuse is an action inconsistent with general medical industry practices. It exploits fact to gain something of value.
For example, if an employee in the billing department of a medical office creates fake patients and forges documents, they are acting fraudulently. On the other hand, a medical office that charges an extraordinary amount for certain services may be committing abuse.
4. Obtain property or money from a health care benefit program.
Under 18 U.S.C. §24(b), a health care benefit program is any public or private plan that provides medical benefit, item, or service to any individual or provides the payment for those things.
There is no knowledge of, or intent to violate, the federal statute necessary. By providing an insurance company with false or misleading information and receiving property based on that false information, you may be held liable for fraud.
This statute is broad and applies to all licensed medical professionals, non-licensed individuals, and medical practice owners. Health care businesses and even universities may be held liable for health care fraud.
Health Care Assistant and Employee Health Care Fraud Scheme
There are a variety of schemes that are typically viewed as health care fraud, and below are several examples of these schemes, including brief descriptions of what they entail and real-life examples of their resulting convictions.
If you believe that you are involved in a health care fraud scheme or if you are under investigation for accusations of health care fraud, it is imperative that you contact an experienced attorney today.
An experienced and knowledgeable attorney will be able to advise you and guide you from the beginnings of an investigation all the way through to its resolution, which could be nothing or could be a trial.
- Texas Hospital Administrator Convicted of Health Care Fraud for Role in $16 Million Medicaid Fraud Scheme.
On October 9, 2018, Starsky D. Bomer, former Chief Financial Officer and Chief Operating Officer for a Houston hospital, received a conviction for conspiracy to commit health care fraud, conspiracy to pay and receive healthcare kickbacks, and for violating the Anti-Kickback Statute.
From 2011 to 2013 Bomer, and others, paid bribes and kickbacks to group home owners and patient recruiters in exchange for them sending unqualified patients to the hospital’s Partial Hospitalization Program (PHP) – an intense treatment for severe mental health sufferers.
This fraudulent act billed insurance companies for $36.9 million – $16 million for Medicare alone. Read about it by clicking this link or by copying and pasting the URL below:
- Former Employees of Southern California Ambulance Company and Dialysis Center Plead Guilty to Medicare Fraud Charges.
In November 2017, Aharon Krkasharyan, a former employee of Mauran Ambulance Inc., pled guilty to charges of conspiracy to commit health care fraud with Maria Espinoza, a former employee of a dialysis center,
Espinoza would refer the patients and Krkasharyan would file the claims. Most of the patients referred and billed for did not actually require a transfer in an ambulance. As a result of this scheme, Medicare paid out $6.6 million for services never provided.
For more information and the full DOJ press release, click this link or copy and paste the URL below:
- Texas Patient Recruiter Sentenced to Nine Years in Prison for $3.6 Million Home Health Care Fraud Scheme.
In early October 2018, Mercy O. Ainabe, a former patient recruits, received nine years in prison. Ass a patient recruiter, she stole patient information and sold it to home health care agencies for a kickback.
The home health care agencies would then use this patient information to file false claims with Medicare. Ainabe knew of this scheme and furthered it with her actions.
As a result of this scheme, Medicare was defrauded of $3.6 million. For more information and the full DOJ press release, click this link or copy and paste the URL below:
- Patient Recruiter and Staffing Company Employee Convicted of $2 Million Home Health Care Fraud Scheme.
In April 2016, Carlos Rodriguez Nerey, a patient recruiter, received a conviction for one count of conspiracy to defraud the United States, and pay and receive health care kickbacks, and one count of receiving health care kickbacks.
He recruited for two different home health service companies. He received kickbacks for the patient information he provided. The companies used it to bill Medicaid for not rendered services. They billed Medicare for $2.5 million, and Nerey received $250,000 for his role.
For more information and the full DOJ press release, click this link or copy and paste the URL below:
Possible Punishments for Health Care Fraud
If convicted on charges of health care fraud based on actions as a health care assistant or medical service employee, severe penalties may include:
- Up to ten years in prison.
- If, as a result of the fraud, someone suffers from death or serious bodily injury up to twenty years in prison.
In addition, there are severe fines you may face for your role in a federal health care fraud scheme:
- The fines range from $250,000 for an individual defendant or $500,000 for a defendant organization.
- Having to pay back double whatever pecuniary gain was made as a result of the fraudulent scheme.
In addition to criminal penalties, there are several civil penalties and fines that may be imposed:
- Loss of whatever professional medical license held.
- Inability to work as a health care assistant or employee in the medical field again.
How Will a Health Care Fraud Case Proceed?
Enforcement of the Statute
There are several government agencies that are tasked with enforcing the federal health care law statute. The “heavy lifting,” so to speak, typically falls into the Department of Health and Human Services Office of Investigations (HHS-OI), since they are charged with the oversight of the Medicare and Medicaid programs.
The Federal Bureau of Investigation (FBI), the Medicare Strike Force, and the United States Department of Justice (DOJ) will also help in the investigations and enforcement of the statute.
Investigations into Potential Violations
Investigations into potential fraudulent conduct can begin in many ways, such as:
- A patient who not receive proper treatment from their health care assistant but still receives a bill for the untendered services.
- A former, or current employee of the medical office in question may also alert the authorities if they think that fraudulent activity is occurring within the office.
- As a result of questionable results from a Medicare billing audit or other typical investigation.
Note, that if you become the subject of a health care fraud investigation, you should contact an attorney immediately, comply with the warrant you are given but do not answer questions or make statements without your counsel present. It is an unnecessary incriminating risk.
The DOJ will file charges in the appropriate federal jurisdiction – he “jurisdiction” meaning the court that hears the case. This determination is made based on where the criminal activity took place, the victim’s location, or where the defendant lives.
For example, if the medical office is registered as a business in New York, but the fraudulent conduct took place in New Jersey – either may be considered proper jurisdiction for the case to be heard in.
It is imperative to enlist an experienced attorney as soon as possible. Having someone to protect your rights and interests at every level or a case, from investigation to sentencing – if it comes to that, will help to make sure you receive the best result possible.
What You Can Do If You are Under Investigation?
First and Foremost, contact an attorney. Whether you are under investigation or not, an experienced attorney can provide individualized help to ensure that you never become the victim of healthcare assistant fraud.
Our attorneys are a wealth of knowledge in medical billing and coding, the different health care fraud schemes that commonly affect home health aide services, and the importance of the confidentiality you share with your patients.
Your patients look to you and your office when they are going through hard times. You should let an experienced attorney look after you if you are facing a complex legal issue.