Legal Services For Pediatricians
Health care fraud investigation can occur in various health care practices, including child health care. As an office of pediatricians or as a solo practitioner, you may be vulnerable to being accused of health care fraud.
Without your knowledge, organizations like the U.S. Medicare Fraud Task Force may be conducting audits on your business practices and day-to-day actions. These audits can turn out to be full investigations and could lead to criminal charges or civil suits.
If you have been contacted by law enforcement or have been charged with health care fraud, you will need the assistance of an experienced criminal defense attorney – one who can advise you and guide you through the process.
What Types of Fraud Can Pediatricians Be Charged With?
- the illegal receipt of kickbacks;
- submitting claims for services not rendered;
- unbundling services in order to increase reimbursements;
- and more.
Being Accused of Health Care Fraud
Generally, health care fraud relates to when a pediatrician makes a false statement in order to receive payment or reimbursement from a health care benefits program; however, there are various statutes that can be applied criminally and civilly to determine whether your acts are a violation of the law.
Accusations against you can stem from the way you conduct your practice or from the different colleagues that you are working with. Because there are many different ways that health care fraud can be established, you may not even know that some of your practices violate the many statutes.
Accusations can also include hospital staff, acquaintances, insurance companies, and health care specialists. Even if you think you are conducting your pediatric services within regulations, you could still be investigated or at least audited for health care fraud.
Common Charges Brought Against Pediatricians
False Claims Act – 31 U.S.C 3729-3733 – The False Claims Act prohibits you from making a claim that you provided services to a patient when you did not provide those services. Violating this statute can make you civilly liable to private citizens and the state agencies.
Physician Self-Referral / Stark Law – 42 U.S.C. 1395nn – The Physician Self-Referral/Stark Law is similar to the Anti-kickback Statute below and limits making referrals to individuals you have a financial relationship.
Healthcare fraud 18 U.S.C. § 1347 – Makes it illegal to knowingly and willfully defraud a health care benefit program by making a false representation or statement in order to obtain any benefit from a health care program.
Anti-Kickback 42 U.S.C 1320a-7b(b) – The Anti-kickback Statute makes it illegal for you make referrals to another person or health care provider when the two of you are closely related financially and are making payments for referrals to one another.
False statements in health care matter 18 U.S.C. § 1035 – The false statement statute prohibits you from making false statements, or conceal, falsify, or cover up any material facts, with the purpose of making a claim for payment from a health care benefit program.
Best Defenses to Charges of Fraud Against Pediatricians
If you have been accused of health care fraud, there may be a defense for you. Seeking the assistance of an experienced criminal defense attorney will help in building your defense. By looking at the facts of your cases and the charges against you, an attorney can help defend you against the charges or minimize penalties.
Lack of Intent
A defense could be that you did not have the intent that is required. A look back at the health care fraud statute will show you that intent to defraud is required to be found guilty of this crime, which the government must prove. The may be reasons for your actions that had nothing to do with defrauding any health care benefits program.
For example, if you are accused of false billing, you might have thought you were using the correct code for the procedures that you were providing.
Legal Referrals for Anti-Kickback
While the Anti-kickback Statute prohibits you from making referrals to others when there is a financial relationship, sometimes those referrals could be legal.
For example, if you had a professional relationship where you were renting out an office in your building or for the use of equipment, there could be a possibility that making referrals to each other is not illegal so long as there is no additional benefit from those referrals.
Who Investigates Charges of Health Care Fraud Against Pediatricians?
The federal agencies involved in investigating charges of health care fraud include:
- The Office of the Inspector General (“OIG”);
- The U.S. Department of Health and Human Services (“HHS”);
- The Department of Justice (“DOJ”) Health Care Fraud Unit;
- The Federal Bureau of Investigations (“FBI”) Health Care Fraud Unit;
- The National Insurance Crime Bureau (“NICB”);
- The Coalition Against Insurance Fraud (“CAIF”);
- The National Association of Insurance Commissioners (“NAIC”)
Generally, federal, state, and local agencies will join forces in order to investigate allegations of health care fraud.
Even private insurance carriers play a role in the investigations. Once a health care provider or insurance carrier initiate an investigation into your practice, they are obligated to inform federal, state, and local agencies of any fraudulent activity they become aware of.
Pediatrician Fraud In the News
Nashville Pediatrician Pleads Guilty To False Billing
In late 2013, a prominent Nashville health care provider and pediatrician pleaded guilty to criminal and civil health care fraud for upcoding the services he provided when billing for his services. Over the period ranging from 2007 to 2012, this pediatrician was in the practice of conducting infant auditory screening exams. While the pediatrician was actually providing some services, specifically auditory screens, the auditory screens that were being conducted were not the expensive comprehensive auditory screening exams that were being billed.
During the investigation, it was found that the pediatrician did not even have the necessary equipment required to conduct the comprehensive exams, and admitted that there were occasions when the members of his staff had informed him that the services billing for were not actually being performed. When his staff requested that the equipment be purchased, the pediatrician denied their request.
The case ended in the pediatrician pleading guilty that included both criminal and civil violations. The pediatrician now must pay more than $1.6 million in restitution and is banned from federal health care programs for a period of 20 years.
New Jersey Pediatrician Guilty of Fraudulent Treatments
A New Jersey pediatrician, Badawy, pleaded guilty of health care fraud for making claims that he was providing services to patients that were fraudulent and in 2015, he was sentenced for those violations.
As part of the plea, Badawy pleaded to one count of healthcare fraud where the facts showed that over a period of four years (from 2004 to 2008), he submitted claims for superficial wounds around patients’ face and ears that were either not completed or unnecessary. The problem with these services is that they were essentially repairs of previously closed wounds. Many of these treatments were conducted on children.
The penalties that Badawy had to face were no slap on the wrist- Badawy was ordered a prison term for a period 21 months, ordered to serve three years of supervised probation, and was fined $5,000. Additionally, he had to pay restitution in the amount of $196,911, which was the equivalent of the payments he received from Medicaid.
Georgia Pediatric Services Gets Large Fine To Resolve Health Care Fraud
The Georgia Pediatric Services were sued under the False Claims Act for not complying with federal health care requirements and paid a hefty fine in their settlement. As a result of a qui tam/whistleblower suit, authorities was found that Georgia Pediatric Services was failing to conduct inspections of their records. In order to participate in the federal health care program, you must also investigate your records to check for overpayments. If you find overpayments, you must return them.
Georgia Pediatric Services of America did not inspect their books and, naturally, did not return any overpayments. As a result, they and their related entities (four additional locations) had an overage well into the millions that had been overpaid. Overall, it was found that Georgia Pediatric Services failed to return overpayments, submitted claims for home nursing visits without ever actually documenting the visits by a registered nurse, and claimed that their services were taking a longer length of time than the time the services actually required.
These acts ultimately amounted to Georgia Pediatric Services paying around $6.88 million to resolve the health care fraud and False Claims Act allegations
Pediatrician Accused of Giving Improper Doses of Vaccines
A Florida pediatrician whose services included administering vaccines through the Vaccines for Children Program was accused of health care fraud for administering the incorrect dose of vaccines to children that were covered by both Medicaid and private insurance programs.
The Florida Department of Health has alleged that this Florida pediatrician only gave partial doses of the vaccines she claimed to be providing. These vaccines were to prevent protection from diseases that are classified as “potentially dangerous.”
While the case against this Florida pediatrician is still pending, she has now been suspended from the program. Additionally, she was placed on a corrective plan and was only able to receive a limited amount of vaccinations for a period of two months. So far, this Florida pediatrician has been charged with Medicaid fraud.
Links to the Government Press Releases Discussed Above https://archives.fbi.gov/archives/memphis/press-releases/2013/prominent-nashville-pediatrician-and-former-owner-of-centennial-pediatrics-pleads-guilty-to-health-care-fraud https://www.fbi.gov/contact-us/field-offices/newark/news/press-releases/jersey-city-new-jersey-pediatrician-sentenced-to-21-months-in-prison-for-billing-medicaid-for-bogus-treatments https://www.justice.gov/usao-sdga/pr/pediatric-services-america-and-related-entities-pay-688-million-resolve-false-claims https://abcnews.go.com/US/florida-pediatrician-accused-administering-half-doses-vaccines-patients/story?id=53391827
How You Can Help Prevent Allegations of Health Care Fraud?Some of the best ways to not be accused of health care fraud are to follow the statutes and regulations. However, there are a lot of instances where you may be working in a larger office that includes multiple practitioners and staff members in which their actions can cause criminal charges against you. To help prevent these charges you should:
- Maintain good records
- Conduct internal investigations
- Any agreements with other entities should be written