If you become of a healthcare fraud investigation regarding any part of your practice or associated practices, you should consult with an experienced federal criminal defense lawyer before speaking to any investigators or law enforcement. You may not be the target of the investigation, but you will stronger protection against possible prosecution if you retain an attorney early on.

Healthcare fraud involves the intentional deception or misrepresentation to benefit from any federal healthcare program or insurer. Medicare, Medicaid, federal worker’s compensation, and Tricare are a few of the common programs where fraud typically occurs. Fraud can be committed by doctors, patients, or even third-party businesses such as clinics and hospitals.

Individual healthcare consumers can commit healthcare fraud several ways:

• Providing false information in an insurance claim to maximize the benefits

• Forging or altering a receipt or invoice

• Using coverage of another individual

• Using the insurance card of another individual

• Filing of a claim for a medication or service not received.

Healthcare professionals and businesses can commit healthcare fraud several ways as well:

• Billing and coding errors

• Billing for unnecessary supplies, equipment, or services

• Billing for supplies, equipment, or services that were not provided

• Faking a patient’s diagnosis to justify unnecessary tests and procedures

• Upcoding – billing for a service that costs more than what was performed

• Unbundling – driving up costs by billing each stage of a procedure separately

• Accepting kickbacks for patient referrals

• Self-referrals – referring patients to service entities where the doctor has ownership or investment

• Fraudulent certifications.

Many healthcare fraud investigations start out as civil cases, but they can quickly escalate into criminal cases, depending upon the facts of the case. It is vital to have legal protection as early as possible in the investigation.

Penalties

Numerous cases are the result of simple mistakes, but these mistakes can easily lead to serious legal consequences. A civil case can result in forced repayment of claims or the denial of future claims. A patient may be barred from government healthcare programs, while a healthcare professional could face a state’s disciplinary board and lose their license. A criminal case, on the other hand, involves heavier penalties. At the federal level, criminal penalties for healthcare fraud depend on which law was violated and the amount in controversy, e.g.:

• Under the False Claims Act, penalties may include a maximum of five years in federal prison, a maximum fine of $250,000, recoupment, licensing action, and/or program exclusion.

• Under the Anti-Kickback Statute, violators may be jailed up to five years and fined up to $75,000 per violation.