Legal Assistance for Physical Therapists
- Billing and Administrative Staff
What Is Health Care Fraud
Like other regulations, health care fraud is governed by statutes. These statutes generally regulate the making of a fraudulent or false statement for the purpose of receiving a payment or benefit from a health care benefit program. There are three main statutes that can be applied, and while they may look the same, they each have a different meaning.
Statutes That Regulate Health Care Fraud
This criminalizes the act of knowingly and willfully defrauding a health care benefit program when a person uses false representations and statements to obtain any payment or good from a health care program.
The anti-kickback statute applies when you enter into an agreement with another person who is closely related financially, and the two are in the business of referring patients or making payments for referrals to one another.
False Statements in Health Care Matters 18 U.S.C. Section 1035
The false statement statute makes it illegal to make a false statement, or conceal, falsify, or cover up a material fact, in order to make a claim for payment from a health care benefit program.
False Claims Act – 31 U.S.C 3729-3733
You can be civilly sued for making a claim that your provided services to a patient when you actually did not provide those services.
The Stark law is similar to the anti-kickback statute above.
The Penalties For Health Care Fraud
Healthcare Fraud – 18 U.S.C. Section 1347
If you are found to have violated 18 U.S.C. Section 1347 there is a possibility of up to 10 years in prison or a fine or both. The prison sentence can extend to 20 years if the government finds that your fraud caused serious bodily injury of another.
Kickbacks – 42 U.S.C 1320a-7b(b)
If you are found to have violated 42 U.S.C 1320a-7b(b), you could face up to five years of imprisonment or a fine of up to $25,000 or both.
False Statements – 18 U.S.C. Section 1035
If you are found to have violated 18 U.S.C. Section 1035 you can face up to five years in prison or a fine or both. While the fine is not specified for this statute, the government and the court will likely look to the amount that needs to be reimbursed or that you are accused of benefiting from and will then determine the amount.
A violation of these statutes can lead to harsh criminal penalties and high civil fines. The penalties do not stop there; you could also lose your job and certifications that you may have. Being represented by an experienced federal criminal defense attorney could help fight the charges against you and to minimize any penalties you may be facing.
Physical Therapist Fraud In The News
A Detroit Physical Therapist And Recruiter Sentenced for Health Care Fraud Scheme
In 2009, a physical therapist and one of his recruiters pleaded guilty to a health care fraud scheme and were sentenced to prison. The physical therapist admitted to entering into an agreement with a rehabilitation center to recruit patients that focused on therapy and provided infusion and injection therapy services.
In his admission, the physical therapist said that he was part of a scheme that included making fake files of patients to claim that services had been performed when they did had not actually been performed.
The recruiter admitted that he paid patients to visit the rehabilitation center, or to sign paperwork saying they received physical therapy services, even when they did not. This act was considered a kickback because of how patients were being paid to claim services were rendered.
The government found that these two individuals billed about $9.1 million for medical services, many of which were never provided. The physical therapist was sentenced to 48 months in prison and had to pay $6.09 million in restitution. The recruiter was sentenced to three years of probation and was ordered to pay $772,800 in restitution.
Physical Therapist In Brooklyn Pleads Guilty To False Billing
In 2011 a physical therapist pleaded guilty for submitting false claims. Part of his acts included falsely claiming that he was providing services when they were not being provided, or providing services that were medically unnecessary.
As part of these false claims, the physical therapist hired unlicensed and uncertified individuals to perform these treatments. Regardless of these individuals not being licensed, the physical therapist still claimed to Medicare that a physical therapist was completing the services in order to receive a larger benefit from the health care benefits programs.
The government determined that over the course of five years, this physical therapist submitted $11.9 million in false claims. The plea of guilty in this case was to five separate counts, which will cause the physical therapist to face up to 10 years of prison for each count (up to 50 years total). This does not include the number of fines that the physical therapist will face.
San Diego Health Care Provider Uses Unauthorized Physical Therapists, Pays $1.5 Million
In early 2018 a health care system based out of San Diego agreed to pay a fine in order to resolve the allegations against them that supported violations of the False Claims Act.
During the investigation of the case against the San Diego health care provider, it was found that they used the services of a physical therapist and billed those services to Medicare and TRICARE. Depending on the type of insurance, a requirement may include only using service providers that enrolled within their system.
For instance, in order to bill Medicare and TRICARE, you must be an enrolled provider with billing privileges. In some instances, the billing requirements were extended to unenrolled providers so long as that provider was directly supervised by a physician.
Unfortunately for the San Diego health care provider, they were not directly supervising the services provided by the unenrolled physical therapists. Yet, the health care provider was still submitting claims for the unauthorized services provided. This led them to be sued under the False Claims Act.
How To Avoid Health Care Fraud Charges
Not every practice is perfect; however, you should be taking steps to eliminate or limit health care fraud in your office. These steps should include:
- Keeping good office records
- Having any business agreements reduced to writing
- Screening referrals for conflicts
- Report fraud when it is discovered
Contact a Health Care Fraud Attorney Today
If you are being investigated or have been charged, it is important to seek the assistance of a criminal defense attorney to analyze your facts and files to determine whether there is a strong case against you.