Health Care Fraud

As the costs of health care have risen, so too have allegations of health care fraud.

While all health care programs are subject to fraud, the most visible examples have been those involving the Medicaid and Medicare programs, from which 3 to 10 percent of all payouts are estimated to be “improper.”

At Jacobs Keeley, our health care fraud defense attorneys are committed to defending health care professionals and health care institutions accused of fraud. The fact is, health care representatives have to comply with onerous and extensive regulations and civil statutes, and the array of criminal laws is ever-widening.

Years ago, federal prosecutors primarily focused efforts on criminal cases against “phantom billing” or “ghost billing,” which involved payment for services not rendered or goods not provided. These cases were often cut-and-dry in terms of reaching the burden of proof.

Today, these investigations are increasingly complicated as they involve investigations into whether the services or goods were “medically necessary” or whether services may have been “up-coded.” These are far more subjective terms, and there is ample opportunity for prosecutorial error. This is especially true when we’re talking about systems and requirements that are exponentially more complex than they were a decade ago.

In many cases, expert witnesses become central to the defense, and it’s important to have an attorney who can effectively orchestrate a good strategy for how to best utilize all available resources.

Health Care Fraud Prosecutions

To target health care fraud, Congress enacted 18 U.S.C. 1347. The statute holds that whoever knowingly and willingly executes or attempts to execute a plan to defraud any health care benefit program or to obtain money or property of these programs commits a felony punishable by up to 10 years in prison.

If the violation is found to have resulted in serious bodily injury, that penalty is upped to 20 years. Almost all health care fraud investigations are handled at the federal level by the FBI.

In FY 2011, the agency had 2,690 pending health care fraud cases, which was an uptick of 10.5 percent from just four years earlier. That year, the agency reported:

  • $1.2 billion in health care fraud restitution.
  • $1 billion in fines.
  • $329 million in civil restitution.
  • $1 billion in civil settlements.

The different kinds of health care fraud run the gamut:

  • Falsifying a patient’s diagnosis to justify unneeded tests.
  • Unbundling by billing each step of a procedure as if it was separate.
  • Offering or receiving kickbacks for referring patients.
  • Routinely waiving patient deductibles while overcharging insurers or the government.
  • Upcoding, or billing for more expensive services or goods than what was actually provided.

A conviction in these cases can be serious. Not only will providers face prison time, they will likely not be able to practice again upon release.

Per F.S. 456.0635, effective July 1, 2012, health care boards and/or the department of health must refuse to issue a license, certificate or registration to applicants convicted of a felony. Those convicted of (or having plead nolo contendere to) health care fraud specifically have to wait at least 15 years from the date of conviction in order to reapply to practice.

Health Care Fraud Defense

It is common in these cases for evidence to include mass quantities of computer-generated data. Many times, it’s necessary for defense firms to hire expert witnesses to comb through this data and offer meaningful analysis to help combat the prosecution’s position.

Additionally, there also tends to be many potential witnesses in health care fraud cases. Determining which are most valuable, which pose the greatest threat and how to utilize that information in a way that bolsters your case will require the aid of an experienced defense lawyer who is confident in handling these types of criminal fraud cases.

Health care fraud defense requires substantial investigation, thorough document review and full analysis of all materials and witness statements within the government’s possession.

It’s important to understand that because of the complexity of the laws and billing systems, honest errors are common. Because even prosecutors don’t have a firm grasp of these systems, sometimes criminal charges are entirely unwarranted. In other cases, the charges are more severe than what the facts support.

Our experienced defense team is ready to help you put such charges behind you.

Contact the Miami Health Care Fraud Defense Lawyers at Jacobs Keeley Trial Lawyers for a confidential appointment to discuss your rights.

Call us at (305) 358-7991.

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