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What Is Health Care Fraud?

health care fraud

 

Dr. Nick Oberheiden, Esq.
www.federal-lawyer.com
(214) 692-2171
Including Weekends

Healthcare fraud typically involves an attempt to obtain money or other items of value from a healthcare company or government program through false and fraudulent representations.  In most healthcare fraud trails, the intent of the defendant or defendants is a central issue; in other words, the jury is asked to determine whether the accused purposefully sought to fraudulently obtain payment from the healthcare payor.  The government usually relies heavily on errors in billing or coding to demonstrate that defendant’s intent to defraud the healthcare company.  However, such errors – even if they are repetitious – clearly do not definitively prove that the defendant intended to defraud the government by making a false claim.

Burden of Proof

To prevail in a healthcare fraud trial, the government must prove that the defendant knowingly participated in a scheme to defraud either a federal healthcare program (DOL, Tricare, Medicaid, Medicare), a state or local healthcare program, or a private insurer.  For criminal trials, the burden of proof is beyond a reasonable doubt.  In civil trials, the burden of proof is a preponderance of the evidence.

Common Examples

Healthcare fraud encompasses a wide variety of conduct; the common thread is that the actions at issue were carried out for the purpose of illegally obtaining a benefit for a healthcare provider at the expense of the state or federal government or private insurer.  Below is a non-exclusive list of the types of cases the government commonly prosecutes:

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Dr. Nick Oberheiden
Dr. Nick Oberheiden

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Amanda Marshall
Amanda Marshall

Former U.S. Attorney

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Lynette S. Byrd
Lynette S. Byrd

Former Federal Prosecutor

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Aaron L. Wiley
Aaron L. Wiley

Former Federal Prosecutor

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Subodh Chandra
Subodh Chandra

Former Federal Prosecutor

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Elizabeth K. Stepp

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Roger Bach
Roger Bach
(Non-Lawyer)

Former Special Agent, OIG

Dennis A. Wichern
Dennis A. Wichern
(Non-Lawyer)

Former Special Agent-in-Charge

Chris Quick
Chris Quick
(Non-Lawyer)

Former Special Agent, FBI

Kevin M. Sheridan
Kevin M. Sheridan
(Non-Lawyer)

Retired Supervisory Special Agent, FBI

Ray Yuen
Ray Yuen
(Non-Lawyer)

Former Supervisory Special Agent, FBI

Gamal Abdel-Hafiz
Gamal Abdel-Hafiz
(Non-Lawyer)

Former Supervisory Special Agent, FBI

  • Fraudulent certification occurs when a person fraudulently signs or forges a required certification, such as a certification that services were actually provided or were medically necessary.  Healthcare payors often require several such certifications from healthcare providers.
  • Upcoding occurs when a provider submits a claim for a procedure or service that is paid at a higher rate than the procedure or service actually performed.
  • Unbundling is another method of gaming the billing codes, in which the healthcare provider separates out procedures that are commonly billed as one group in order to obtain additional payments for each part of the group procedure.
  • Services not rendered, or “phantom billing”, occurs when a healthcare provider submits a bill for a procedure or service that was never performed.
  • Imaginary patients or “ghost patients” are patients for whom a provider falsely claims to have performed services or procedures to or persons who were never seen by the provider.
  • Lack of medical necessity is charged when the government alleges that, despite receiving the proper certification, the services rendered to the patient were not medically necessary.
  • Kickbacks are one of the biggest areas of healthcare fraud and involve providing compensation in exchange for referrals. It is illegal to pay for any referral of a government healthcare patient in any manner, whether monetarily or through gifts.  Both the person offering the payment and the person receiving the payment may be charged for participating in a kickback scheme.
  • The Stark Law prevents physicians from maintaining a financial interest in services to which they refer their patients, such as toxicology labs and pharmacies. There are several safe harbor exceptions to the Stark Law that must be closely followed to comply with the law.

Penalties

Our ultimate goal in each of our healthcare fraud representation is to avoid criminal investigations.  Whether civil or criminal, healthcare fraud penalties can be extremely severe and include recoupment requests, non-payment of future claims, civil fines of up to $ 11,000 per false claim, exclusion from federal healthcare programs, treble damages, attorney fees, criminal fines, criminal indictment, or imprisonment.  We often succeed in keeping such investigations on the civil path, protecting our clients’ medical licenses and freedom.

Defending Healthcare Fraud

At Oberheiden, P.C., our team of former healthcare prosecutors and experienced defense attorneys have a distinguished history of protecting individual providers, hospitals, laboratories, pharmacies, home healthcare entities, and many other healthcare business owners against charges of healthcare fraud, whether civil or criminal in nature.  In most instances, such investigations have resulted in a formal statement by the government that our client had no civil or criminal liability. Recent examples include:

  • Medicare Fraud
  • False Claims Act Violations
  • Tricare Fraud
  • Stark Law Investigations
  • Anti-Kickback Investigations
  • Medicare Audit
  • Department of Labor Investigations
  • FBI, DEA, FDA, and Medical Board Investigations
  • OIG Subpoenas
  • Grand Jury Subpoenas

Our Track Record

  • Defense of Medicare laboratory against investigations by the Department of Justice and the U.S. Attorney’s Office for alleged Medicare Fraud
    Result: No civil or criminal liability.
  • Defense of a healthcare services company against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged False Claims Act and Stark Law violations
    Result: No civil or criminal liability.
  • Defense of Medicare laboratory against investigations by the Department of Health and Human Services and the Office of Inspector General for alleged Healthcare Fraud.
    Result: No civil or criminal liability.
  • Defense of nationally operating healthcare company against an investigation by the Department of Defense for alleged Tricare fraud.
    Result: No civil or criminal liability.
  • Defense of healthcare marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare violations.
    Result: No civil or criminal liability.

We are available every day of the year, 24 hours a day. You can call us directly or complete our contact form or by emailing us directly.

(214) 692-2171
Including Weekends
This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. Oberheiden, P.C. is a Texas LLP with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.

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