What is Healthcare Fraud?
Healthcare Fraud Legal Defense Team
The scheme to defraud a healthcare program normally involves false or fraudulent representations designed to access something of value— usually money. The intent of the accused is almost always the central issue at any healthcare fraud trial. Many times errors in billing and coding make up a large part of the government’s case against a defendant. That being said, the mere fact that there are errors in bills and coding submitted does not necessarily mean that a defendant had the requisite intent to defraud a health insurance program.
Burden of Proof
When an individual is accused of healthcare fraud, the government has to prove that the defendant engaged in a scheme to steal from a healthcare program, such as Medicare, DOL, Medicaid, Tricare, another government insurance program or a private insurance program.
As seen, healthcare fraud is a generic term that encompasses a variety of conduct designed to illegally obtain a financial benefit of a provider to the detriment of the state or federal government. The following list is not exclusive, but it summarizes some of the most common healthcare fraud examples.
The federal Anti-Kickback Statute is a criminal statute that prohibits persons or entities from knowingly and willfully soliciting, receiving, offering, or paying remuneration for referrals for goods or services payable to a government healthcare program, such as Medicare, Medicaid, and Tricare. This statute is designed to prevent fraud and abuse. Kickbacks may include referral fees, finder’s fees, bonuses, discounted leases, research grants, excessive compensation, and travel or entertainment.
Billing of government and private insurance programs utilize numerical codes that identify the specific procedure or service being performed. For every necessary procedure, government healthcare programs assign a dollar amount it will pay. Up-coding occurs when a healthcare provider submits claims for healthcare services that represent a more serious and/or more expensive procedure than what was actually performed. Up-coding is a form of healthcare fraud and may be a violation of the False Claims Act.
Services Not Rendered
Billing for services not rendered is a form of healthcare fraud that consists of submitting claims for healthcare services that were never rendered.
Ghost patients are patients who either do not exist or who never received the service or item billed for in the claim. Submitting claims for healthcare services of ghost patients are a form of healthcare fraud.
Inflating Cost Reports
Medicare reimburses hospitals and healthcare institutions for certain costs for the treatment of particular patients. These hospitals and healthcare institutions are required to file Cost Reports with Medicare. One common type of healthcare fraud has been for hospitals or healthcare institutions to inflate the costs on their Medicare Cost Reports, or to otherwise falsify information on these cost reports to maximize Medicare reimbursement. Cost report fraud scenarios may include falsely inflating costs related to patient care; seeking reimbursement for costs that are not related to patient care; seeking reimbursement for costs for non-Medicare patients; and improperly manipulating statistics.
Medicare Part D Fraud
In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which added “Part D” to the Medicare Program. The Part D program consists of prescription drug coverage and prescription drug insurance premiums. Since its enactment, it is expected that the Part D program will be the target of substantial fraud in the coming years. Forms of Medicare Part D Fraud include claims of duplicate billing; overcharging; enrollment fraud; red-lining; and improper rebates from pharmaceutical manufacturers and wholesalers.
Lack of Medical Necessity
In order to qualify for payment by government healthcare programs, healthcare services must be medically necessary. healthcare providers are required by law to document the medical necessity of the treatment or services for which they are seeking reimbursement. Submitting claims for services, treatments, diagnostic tests, and medical devices that are not medically necessary is a common type of healthcare fraud.
Improper Financial Interest
Federal and state laws and regulations prevent physicians and other healthcare providers from having a direct or indirect financial interest in certain services provided to their patients. An example of this is the federal Stark Law, 42 U.S.C. § 1395nn and § 1396b. The Stark Law prohibits a physician from making a referral for certain designated health services to an entity in which the physician has an ownership or investment interest or with which he or she has a compensation arrangement. In addition, the Stark law covers investments and compensation paid to any member of the physician’s immediate family. Violations of the Stark Law or another federal can also result in a violation of the False Claims Act.
Bundling & Unbundling
A common type of healthcare fraud has been to “unbundle” procedures or tests and bill each one separately, which pursuant to Medicare and Medicaid guidelines are to be billed together. Medicare and Medicaid often will have lower reimbursement rates for groups of procedures commonly performed together. And, unbundling billing codes illegally increases a provider’s profits, resulting in greater reimbursement from Medicare and Medicaid.
Physicians, hospitals and other healthcare providers are required to provide certain certifications when submitting bills to government healthcare programs, such as Medicare, Medicaid, and Tricare. These certifications include medical necessity, actual performance, and regulatory compliance. In addition, healthcare providers that provide goods or services to government healthcare programs must satisfy all contractual obligations with the government. Falsifying such certifications in order to get a health care claim paid or to obtain additional business is a form of healthcare fraud and may also be a violation of the False Claims Act.
The goal we have when representing clients accused of healthcare fraud is to avoid criminal investigations. Oftentimes, an experienced healthcare fraud defense lawyer, such as one of our former federal prosecutors, is able to channel a healthcare fraud case onto a civil path so that a provider’s license and freedom remain untouched and intact.
Defending Healthcare Fraud
Our team of former healthcare prosecutors and experienced fraud defense attorneys have a long and distinct history of defending individual providers, hospitals, laboratories, pharmacies, home healthcare entities, and many other healthcare business owners against civil and criminal healthcare fraud allegations. Most of these cases resulted in a formal statement by the government at the end of the investigation that our client had no civil or criminal liability. Recent examples include:
The defense of mistake can sometimes be effectively employed when an accused’s business has a valid compliance program. This fact can assist the defense in pointing out that the errors discovered were inadvertent. It is important to note that the existence of errors does not mean that a fraud has occurred. For example, in Jones v. Simpson, the Supreme Court held that fraud is never presumed, and the burden of proof is always on the government to prove fraud beyond a reasonable doubt.
A Team You Can Trust – Fraud Defense Attorneys
Selecting the right healthcare fraud defense lawyers to help you navigate the complexities of a criminal indictment is essential. Knowledgeable lawyers can help clients determine the appropriate defenses to raise in court, meet with the government with the goal of reducing the criminal charges against you, explore factors that may lessen the severity of the punishment, or work with the government in order to reduce or eliminate jail time. Ultimately, the role of a good healthcare fraud defense law firm is to help you develop a strong defense strategy. Contact us today!
Contact Oberheiden, P.C. online today.
The Oberheiden, P.C. appears in governmental investigations across the country. Our attorneys have obtained no civil or criminal liability outcomes for their clients and were able to dismiss the government’s case in the following areas:
- False Claims Act
- Qui Tam Defense
- Medicare Fraud
- Medicaid Fraud
- Tricare Fraud
- Stark Law Violations
- Physician Self-Referrals
About Oberheiden, P.C.
With many years of experience in criminal defense, the attorneys at Oberheiden, P.C. are experienced to guide you in your lawsuit. When it comes to defending clients, Oberheiden, P.C. approaches each case with maximum dedication and determination and with the objective to get each and every client the absolute best outcome under the circumstances. Individual and corporate clients from across the United States hire Dr. Nick Oberheiden and his team seeking protection against expected or pending criminal charges and government investigations.
Oberheiden, P.C. appears in governmental investigations across the country. In 2015 alone, our attorneys have obtained no civil or criminal liability outcomes for their clients and were able to dismiss healthcare fraud investigations involving the following government agencies.
- Successful defense of a healthcare services company against an investigation by the Office of Inspector General
- Successful defense of Medicare laboratory against investigations by the Office of Inspector General for alleged Healthcare Fraud
- Successful defense of healthcare marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare violations
- Successful defense of a physician owned entity against an investigation by the Office of Inspector General
- Successful defense of a physician owned entity against an investigation by the Office of Inspector General for alleged Stark Law violations
- Successful defense of a physician owned entity against an investigation by the Office of Inspector General for alleged False Claims Act violations
- Successful defense of a physician owned entity against an investigation by the Office of Inspector General for alleged fraud