Legal Services for Long-Term Health Care Facilities
Health care fraud is an area the United States government has taken very seriously for some time now. Investigations into your long-term care facility by the federal government could lead to both criminal charges and civil lawsuits.
Investigating Health Care Fraud
Investigations into health care fraud can happen in many ways including either a whistleblower tipping off the United States government or even the United States government health care task force auditing your medical care benefit submissions.
If you find that you have been accused of health care fraud, the attorneys at the Health Law Group have successfully represented clients across the country. In addition, our health care attorneys can represent you or your long-term health care facility in criminal and civil allegations in both the Federal and State courts.
If you or your long-term health care facility is being accused of health care fraud, contact our office to speak with one of our experienced health care attorneys to review your case.
Statutes That Apply To Long-Term Health Care Facilities
Health Care Fraud 18 U.S.C. Section 1347
As a long-term health care facility, you could be accused of health fraud if you are suspected of having defrauded a health care benefit program by fraudulently making a claim for a benefit or good when you did not provide any services that you are claiming.
When you are alleged to have committed health care fraud, your accuser must prove that you purposely and voluntarily, either succeeded or attempted to defraud a health care benefit program. And that you did so to obtain reimbursement from the health care program.
Penalties For Health Care Fraud
As a long-term health care facility, you can face various penalties for health care fraud and often you will be looking at a range of penalties. For example, if you plead guilty or if you are found guilty for health care fraud, there is a possibility that you can serve a term of prison and that term can be for up to ten years.
Additionally, you could possibly only face a fine. There is a possibility that you could be ordered a prison term and a fine. Depending on whether any of your patients suffered injuries if the care you provided resulted in serious bodily injury or death, the term of prison could be 20 years.
Anti-Kickback 42 U.S.C. 1320a-7b(b)
As a long-term health care facility, depending on the business deals you make with other health care providers, you could be charged with violating the anti-kickback statute if you have made a referral to another person 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 knowingly and willfully received or solicited remuneration. And that you did so in exchange for the referral of a patient or arranging services (including goods and equipment) that are part of a health care program
Penalties For Anti-Kickback
As a long-term health care facility, in the event that you are found guilty of a violation of the anti-kick statute, the penalties include:
- 5 years in prison
- A fine of up to $25,000
- A fine with a prison sentence
False Claims Act – 31 U.S.C 3729-3733
The false claims act is similar to the criminal health care fraud statute. In the instance you are sued for the false claims act, you will be sued on a civil basis. As a long-term health care facility, the United States government or a private citizen can sue you for any claims, that you make stating that you provided medical services when you did not provide those services.
Penalties For Violating The False Claims Act
The penalties for violating the False Claims Act you will result in you to be subject to a fine. This fine will generally have a range from $5,000 to $10,000. Fines will always depend on the facts of your particular case. However, regardless of this fine, you could pay a lot more than $10,000.
Depending on the facts of your case and the damages that you may have caused, the government will request that you pay restitution or pay a refund for those damages. If you happen to settle your case, it is almost guaranteed that you will pay restitution or a refund.
Defenses for Long-Term Care Facilities Against Accusations of Health Care Fraud
If you or your long-term health care facility has been sued or charged with health care fraud, you will need a defense to fight your case.
Depending on your situation and the allegations against you, the type of possible defense available to you will vary. Most defenses are case and fact-specific; however, some can also be statutorily applied.
However, if you work with an experienced defense attorney, a thorough review of the case and discussion of the facts can help to establish a defense that may get the case dismissed or result in less severe sanctions and penalties.
Statute of Limitations
There is a period of time that one must bring a suit against you. This is called the statute of limitations. If a person fails to bring a lawsuit or charges against you, they will be barred from doing so.
Factual defenses are often different than the statutory defenses. This because they depend on your specific facts relating to your case. While they include legal arguments, the facts of your case can support a defense that you did not have the requisite state of mind because the health care fraud that you are being accused of was actually a mistake.
Long-Term Health Care Facilities and Health Care Fraud in the News
Two Georgia, Long-Term Care Centers, Settle For Health Care Fraud Claims
In 2016 two hospitals out of Georgia, Dubuis Health System and Southern Crescent Hospital for Specialty Care agreed on a settlement with the United States government for their role in submitting false claims to Medicare. They provided health care services to patients who needed long-term acute care – acute care is care lasts 25 days; while long-term acute care lasts longer.
From the investigation, the United States government alleged that these hospitals were taking advantage of the higher reimbursement rate that long-term acute care receives from Medicare. Part of the reason for the higher reimbursement is because these hospitals are certified for this type of care.
The allegations focused on a period of six years, from 2003 to 2009, where the United States government found that these hospitals were billing and keeping patients at their centers for a longer period than what would be considered medically necessary.
The United States government concluded that the reason the hospital kept the patients for longer than necessary periods was for two reasons. First, to increase the amount of Medicare reimbursement they were receiving. Second, to be able to maintain their certification and classification as a long-term facility.
As part of the settlement for these False Claims Act allegations, the hospitals agreed to pay $8 million.
Tennesse Long-term, Health Care Center, Settles on Stark Law and Kickback AllegationsIn 2017 a Tennessee health care center settled allegations against them for health care fraud which included the following violations:
- Stark Law,
After investigations by the United States government, it was alleged that the health care center was paying physicians bonuses and salaries at levels above the fair market value which violated both the anti-kickback statute and the Stark Law.
Also, there were allegations that the physicians at the health care center were upcoding services to claim larger amounts to Medicaid for a larger return. The last claim revolves around the services provided versus the services claimed, as the health care center billed for physician visits of cardiac rehabilitation therapy when the physicians never supervised the therapist.
In order to settle these allegations and the complaint against them, the health care center agreed to pay a total of $2.9 million.
New York Long-Term Health Care Provider Settles False Claims Act For Not Returning Benefits
In 2018 the United States government and the State of New York settled with a long-term care program that provided adult home care for acts that led to allegations of health care fraud.
As part of the investigation by both the state of New York and the United States government, the two entities alleged that the long-term health care facility submitted claims for Medicaid to receive benefits for health care services they never provided. They supported their claims by showing that the long-term health care center had 186 patients who lived in adult homes.
For those individuals, the health care center was submitting monthly capitation payments. After looking at the history of the patients, the government found that there were periods when some of the patients did not actually receive long-term care. In reality, the patients should have been dis-enrolled.
The government alleged that regardless of knowing about the dis-enrollment requirement, the health care center continued to submit claims and collect benefits even though they were not entitled to the benefits and should have returned them.
When the health care center settled their case, they admitted that from 2012 to 2015 that they did not provide the claimed services to these patients. In certain instances, many of the patients did not even have records of services. Some of the services claimed to be provided were supposedly given to patients no longer eligible.
The health care center admitted to knowing what they were doing; regardless, they did not repay Medicaid. Overall to settle these claims, the health care paid both the United States government and the state of New York a total of $10.3 million.
Steps To Take If Your Long-Term Health Care Facility Is Being Accused of Health Care Fraud
Penalties for being sued under federal statutes or charged with federal crimes come with steep and severe penalties. As a practitioner and as a long-term health care facility, you should be taking steps to avoid health care fraud.
However, given the daily responsibilities and the large number of encounters that you make with patients and other health care providers, avoidance is not always guaranteed.
You may not be sure if you have taken all safeguards to avoid being accused of health care fraud. However, if you are accused of health care fraud, you should ask yourself what you are being accused of doing specifically. Once you figure that out, stop making that part of your practice.
If the reason you find out about health care fraud is that you are charged or sued with health care fraud, then you should call a defense attorney. Our health care attorneys can help by reviewing your case and by providing legal representation.