Medical and health care fraud are serious issues. Those who commit medical fraud can be charged with a federal crime. This could result in fines, loss of medical licenses, or jail time. That being said, if you find yourself being questioned regarding or charged with medical fraud, you need a healthcare fraud lawyer.
Here’s what you need to know about health care fraud so you can find the best representation available.
What is medical or health care fraud?
Johns Hopkins Medicine defines fraud as “Any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit.”
Medical fraud or health care fraud occurs when a person or corporation knowingly and willfully use a healthcare benefit program dishonestly in order to reap a benefit or turn a profit.
While most medical professionals are honest and hard-working individuals, there are a few who try to line their pockets through illegal actions. They see their crime as victimless since it mainly impacts insurance companies.
Here are the most common medical fraud scams:
- Billing for services not rendered.
- Billing for non-covered services as a covered service.
- Misrepresenting the dates, locations, or providers of service.
- Waiving deductibles or copayments.
- Reporting of diagnoses or procedures incorrectly.
- Overutilization of services.
- General corruption, like kickbacks and taking bribes.
- Unnecessary or false prescriptions.
Is It Fraud or Just a Mistake?
To commit fraud, a person must knowingly engage in fraudulent activities. For instance, a typographical error that results in a patient being billed for a treatment that he or she didn’t receive isn’t necessarily fraud. If, however, a provider knowingly subjects the patient to unnecessary procedures, it counts as fraud.
Keep in mind that claiming ignorance about fraud doesn’t instantly get you off of the hook. While that may be true, it’s the responsibility of insurance companies to investigate anything that looks like fraud. That means that even if you were unaware that someone else in your office is involved in a health care scam, you could still be charged.
Who Can Commit Medical Fraud?
We often think that only medical professionals can commit health care fraud. What they have to gain is clear: simply overbilling or misrepresenting information seems like an easy way to get more money from an insurance company.
However, patients can also be charged with medical fraud. They may try to game the system by faking a medical condition or using someone else’s insurance to receive services.
Punishments and Penalties
Laws vary from state to state, but medical fraud can be pursued under federal guidelines. Medical fraud can be charged as a civil crime, but it is also considered a criminal charge. That means there could be severe consequences for anyone who is convicted.
While it may seem like fraud against an insurance company is a minor crime, it can result in significant penalties.
For example, an individual who makes a false statement in a Medicare claim can be fined up to $250,000 per offense. An organization caught in ongoing schemes can be fined millions or even billions of dollars. A judge may decide that you need to pay back any amounts earned through medical schemes.
This restitution is on top of any determined fines.
As a severe offense, health care fraud can result in prison time. In 2018, the United States Sentencing Commission reported that the average sentence length for health care fraud offenders was 30 months.
Even if the resulting conviction doesn’t result in a prison sentence, it could put you on probation. While probation does mean avoiding time behind bars, it comes with its own set of rules and inconveniences.
Loss of Work
Beyond the potential career issues, you could face having been convicted of a felony, being caught in medical fraud could have other impacts.
Medical providers convicted of fraud could lose their ability to practice medicine or simply have a hard time getting hired to work for a new practice. Patients with felonious fraud on their record could lose their jobs or find it challenging to earn the trust of a new employer.
What do Do if Charged With Medical Fraud
Medical fraud is a severe offense. Even the mere accusation could have significant impacts on your career and reputation. If an investigator approaches you, don’t hesitate to contact a medical fraud lawyer immediately.
A well-seasoned attorney is the best way to navigate the treacherous waters ahead. You may be tempted to negotiate a plea deal or to try to talk your way out of trouble, but this can often result in more trouble and severe punishments.
Typically, the first sign that you’re under investigation is a letter from your Medicare carrier, Program Safeguard Contractor, or a federal agency. The message will look like you are being audited and should include a list of patient cases. These cases contain alleged overpayments or other acts of fraud.
The letter will say that you have time to compile your defense with explanations or justifications for the alleged overpayments. This is when you should contact a medical fraud attorney. They can help file an appeal or to ensure your defense is ready for trial.
You might also be served a search warrant where agents seize files. You cannot obstruct a legal search warrant, but before you let them step foot in your office, verify that they are acting legitimately. Sometimes, someone who claims to represent the government will want to see files without a warrant.
Get a copy of the person’s identification and inspect any badges that are quickly flashed in front of you. If the person does not have a warrant, schedule another time for them to visit and contact a lawyer right away. If there is a legal warrant, pay close attention to what they do and be prepared to fight it later on.
Don’t attempt to change medical records that are under review. That includes destroying or altering any file. Even if the changes are warranted, it can look like you’re trying to cover up something.
Finally, keep in mind that just because you’re being investigated doesn’t mean you did anything wrong. A patient who is accused of fraud might be the focus of the investigation, and you are merely being interviewed. Listen fully to what investigators have to say, but ensure that you have your lawyer on hand before you give them any information.
Find a Health Care Fraud Attorney
If you arrange a meeting with an auditor or investigator, make sure you have a medical fraud lawyer with you.
Don’t try to talk your way out of the situation as you might incriminate yourself, even if you didn’t do anything wrong. Before the meeting, take some time to review the patients and cases under investigation. Don’t let them confuse you; be prepared to answer any questions truthfully and consistently.
Above all, make sure you take all accusations or investigations seriously. We’re not talking about a slap on the wrist. Being convicted of medical fraud can have serious consequences. Contact a medical fraud lawyer right away; your livelihood depends on it.