What Is Considered Healthcare Fraud Under Federal Law?

 

Healthcare fraud is a serious federal crime that occurs when someone intentionally deceives a healthcare program, insurer, patient, or government agency for financial gain. According to the FBI, healthcare fraud causes tens of billions of dollars in losses every year.

If you’re being investigated for healthcare fraud, here’s what you need to know about this type of crime.

You can’t fight healthcare fraud without a lawyer

When you’re being investigated for a federal crime like healthcare fraud, the stakes are extremely high. According to defense attorney Peter Katz, a single count of healthcare fraud can carry a sentence of up to 10 years in prison. Federal agencies conduct their investigations in secret for months or years before the target even knows about the allegations.

If you find out you’re being investigated, federal prosecutors have already built a strong case against you, and it’s critical to bring in an experienced federal defense attorney to protect your rights.

What counts as healthcare fraud

According to federal law, healthcare fraud involves intentional deception regarding benefits, services, or payments. To prove their case, the government needs to prove someone knowingly participated in a scheme to fraudulently obtain money or benefits. This can include:

• Intentional misrepresentation. A mistake or simple billing error doesn’t automatically count as fraud. There needs to be evidence that someone knowingly submitted false information.
• Financial gain. Healthcare fraud usually involves getting money, reimbursements, benefits, or property through deception.
• False statements. Inaccurate records, fabricated claims, altered documentation, upcoding, and false diagnoses are common in healthcare fraud cases.
• Federal program manipulation. Many healthcare fraud investigations involve people deceptively taking advantage of Medicare, Medicaid, TRICARE, and other federal programs.

For conduct to be considered healthcare fraud, it needs to present as a pattern that indicates an ongoing scheme rather than an isolated incident that could be easily explained as a mistake.

Common types of healthcare fraud

The most common forms of healthcare fraud are perpetrated by providers, patients, and third parties in the following ways:

• Billing for services not provided. Hospitals are notorious for billing patients for services that weren’t performed. Providers often submit claims for appointments, treatments, and procedures that never happened.
• Upcoding services. This is when a provider bills for a more expensive service than the one that was actually performed in order to increase reimbursement.
• Unnecessary medical procedures. Some schemes involve recommending tests and treatments that aren’t medically necessary just so the healthcare provider can get paid.
• Duplicate billing. This involves providers submitting multiple claims for the same service.
• Recording the wrong diagnosis. Sometimes a different diagnosis will get a procedure or medication covered by insurance, which gets the doctor reimbursed.

Who commits healthcare fraud?

While healthcare providers are commonly known to commit healthcare fraud, these crimes can also be committed by:

• Patients. Some patients use stolen insurance information, falsify information to gain eligibility, and participate in fraudulent billing schemes.
• Business owners. When healthcare company executives direct or approve fraud, they can be held liable.
• Organized criminal networks. There are large-scale healthcare fraud schemes that operate across the country.

Healthcare fraud is a crime that can be committed by anyone who has something to gain.

Why the government cares about healthcare fraud

Healthcare fraud claims are aggressively pursued because they increase insurance premiums and waste taxpayer dollars. When the fraud involves unnecessary procedures, it puts patient safety at risk.

Potential consequences of a conviction

If you’re convicted of healthcare fraud, the consequences can be severe. In addition to prison time, fines, and probation, you might be required to pay back losses, lose your license, and be banned from participating in federal programs like Medicare or Medicaid.

Federal healthcare fraud is serious

The federal government treats healthcare fraud as a serious offense because it negatively impacts insurers, patients, taxpayers, and healthcare providers. Whether the deceptive conduct involves false billing and diagnoses, unnecessary procedures, or kickbacks, the government will invest extensive resources in their investigations.

If you find yourself the target of a federal healthcare fraud investigation, your best move is to call a lawyer right away. Once you’re informed of the allegations against you, the government already has strong evidence against you. They’ve already reviewed financial records, billing data, emails, and text messages. They may also have information obtained through subpoenas, search warrants, informants, and witnesses.

Don’t risk making statements or agreeing to an interview without talking to an attorney. A qualified federal defense attorney will evaluate your situation, communicate with investigators for you, and help you avoid mistakes that can damage your case.

Healthcare fraud convictions carry severe penalties, so getting a lawyer involved now is the best way to protect your future.