The U.S. health care system is massive and complex, creating many opportunities for fraudulent activity. While most providers operate legitimately, certain unscrupulous individuals seek to exploit loopholes and commit billing scams, putting patient care at risk. If you suspect health care fraud has occurred, an experienced attorney can investigate your situation and advise on potential recourse.
Common Types of Health Care Fraud
Some frequent fraud schemes investigated by health care fraud lawyers include:
- Billing for Services Not Rendered
Providers falsely claim patients received treatments, tests or procedures they did not. This phantom billing wastes insurance funds. - Upcoding Services
Billing insurance for more expensive services than were actually delivered by using billing codes that command higher reimbursement. - Kickback Schemes
Providers paying or being paid by others such as marketers or medical equipment firms in exchange for patient referrals, violating anti-kickback laws. - Identity Theft and Fake Provider Fraud
Criminals assume identities of real doctors and nurses to set up fraudulent clinics and practices to collect insurance payments. - Pharmaceutical and Durable Medical Equipment Fraud
Companies overcharging for drugs or equipment, billing for defective or unapproved products, or engaging in illegal marketing schemes. - Aid Diversion from Government Programs
Misappropriation of Medicare, Medicaid, military or other public health program funds.
Health care fraud harms taxpayers, increases insurance costs, and reduces resources available to those with legitimate needs. A knowledgeable attorney can combat such abuses.
Government Crackdown on Health Care Fraud
Both civil and criminal statutes prohibit deceptive health care business practices. Enforcement has intensified in recent decades as costs rise:
- The False Claims Act allows whistleblowers to file lawsuits exposing fraud and recover damages, with financial incentives. The Department of Justice joins suit.
- HIPAA privacy rules aim to prevent identity theft enabling medical fraud. Breaches face heavy penalties.
- Federal anti-kickback statutes ban payments for referrals between health industry participants due to risk of over-treatment.
- The Affordable Care Act strengthened these laws and boosted anti-fraud budgets of agencies like the FBI, HHS and state authorities.
- Data analytics now detect anomalies in billing suggesting fraud for further investigation. EHR systems facilitate oversight.
- Companies face large financial penalties, healthcare program exclusion, and the threat of criminal prosecution if found guilty of intentional fraud. Individuals also risk imprisonment.
Consulting an attorney experienced in such matters helps assess compliance, respond properly if audited, and represent your interests should fraud allegations arise despite good faith efforts at compliance.
Potential Client or Victim Types
Certain parties have heightened need for a health care fraud attorney’s representation:
- Whistleblowers who report illegal activities confidentially via the False Claims Act, which provides monetary awards for successful cases.
- Medical providers accused of fraudulent billing who require experienced defense. Innocent mistakes may be corrected through settlement versus costly litigation.
- Patients whom identity theft has enabled others to illegally bill in their names. They need help clearing records and obtaining restitution.
- Insurance carriers that uncover broader schemes of overbilling losing them significant money during internal investigations and requiring coordinated legal action.
- Local or state governments defrauded of public health program funds seeking reimbursement and reforms through lawsuits.
- Companies implicated due to alleged anti-kickback, unlawful marketing, or manufacturing/quality issues, who face heavy monetary penalties or bans.
An attorney conversant in the nuances of health care law and enforcement tactics proves invaluable in navigating these situations. Their depth of expertise strongly influences case outcomes.
Investigating and Proving Health Care Fraud Allegations
Even with advanced analytics, uncovering non-obvious fraud demands careful investigation:
- Medical Record Review
Scrutinizing documents for anomalies, missing data, impossibilities suggesting fabricated claims. Expert physicians or coders assist. - Witness Interviews
Contacting providers, patients, billers and others with firsthand knowledge of suspect activities. Whistleblowers frequently emerge. - Financial Auditing
Obtaining banking, tax, inventory and other transaction records for thorough tracing of money flows potentially revealing illegal kickbacks. - Undercover Operations
In serious organized cases, law enforcement may conduct sting operations to confirm criminal conduct. - Data analytics
Leveraging software to detect aberrant patterns, geographical clustering and other red flags across massive claims databases. - Subpoenas and Discovery
Compelling suspects and related parties to turn over communications, records through formal legal processes uncovering incriminating evidence.
Building an ironclad case lays the foundation for either gaining restitution through settlement or prevailing before a jury or judge in criminal or civil court. An attorney ensures each step withstands legal scrutiny.
Settling Health Care Fraud Allegations
When substantial evidence indicates fraud but full prosecution unsure, settlement may benefit all sides to resolve matters efficiently:
- Reach Monetary Settlement
The organization or individual pays back a portion of fraudulent claims to impacted entities and faces stiff financial penalties as a deterrent. - Admit No Guilt But Accept Findings
Settlements often contain no formal admission of liability for defendants, but they must acknowledge investigatory conclusions and corrective steps taken. - Agree to Compliance Reforms
As part of settlements, suspects commonly promise auditing, new procedures and staff training to prevent recurrence under scrutiny of a monitor. - Avoid Program Exclusion and Criminal Charges
Settlement may forestall harsher punishments like being barred from serving Medicare/Medicaid patients or jail time that litigation could bring. - Save on Legal Costs
Resolving before or during litigation spares all parties significant attorney expenditure that may outweigh settlement amounts.
With their industry knowledge and bargaining skills, a specialist attorney strengthens the prospects of a fair resolution when substantial evidence but not 100% legal certainty exists regarding alleged wrongdoing. Settlement prevents further harm while remedying past issues.
Defending Against Health Care Fraud Accusations
For those asserting innocence against accusations, an aggressive defense remains crucial:
- Challenge Investigatory Tactics
Attorneys may argue privacy or procedural violations invalidated key evidence procurement requiring dismissal. - Dispute Fraud Conclusions
Through experts, alternative theories aim to cast doubt that fraudulent intent specifically existed, if irregularities occurred. - Disprove Financial Calculations
Specialized number-crunching tries proving alleged overpayments were within billing variability or resulted from errors, not deception. - Shift Blame to Others
Introducing evidence third parties like vendors, coders or executives bore responsibility shifts focus from client. - Assert Lack of Intent
If fraud laws require willfulness, emphasize training, tools and compliance efforts demonstrate good-faith, mistaken actions at most. - Litigate Constitutionally
Motions question vagueness of charges, agencies exceeding authority or violation of civil liberties like due process during investigations. - Settle Favorably
Once exonerated on major charges, resolving minor issues discreetly becomes preferable to negative publicity from full trial.
An attorney adept at health care regulation and courtroom tactics employed an aggressive yet prudent defense maximizing chances of having accusations dropped or minimized. They protect the innocent when faced with overreach.
Health Care Fraud Consequences
Those convicted of serious health care fraud face grave penalties reflecting the monetary and human costs such schemes impose:
- Fines of up to $25,000 per false claim submitted and imprisonment of up to 20 years per count are authorized by anti-fraud criminal statutes.
- Mandatory exclusion from Medicare and Medicaid programs for minimum periods seriously jeopardizes a medical practice or company’s operations and survival.
- Stiff civil False Claims Act settlements or judgments totaling three times the damages recovered plus sizable per-claim penalties are common.
- Professional license suspensions or revocations prevent further clinical work, jeopardizing careers and futures.
- Suspect entities may face more frequent government audits, monitoring and reimbursement delays owing to “high-risk” designation.
- Criminal fraud convictions severely damage personal and professional reputations beyond legal fallout.
- Shareholders, executives and colleagues suffer embarrassment and reputational consequences from high-profile cases against their firms.
Convictions and serious penalties underscore that health care fraud constitutes no minor regulatory infraction. Top-tier legal representation serves to either clear the innocent or negotiate the least severe outcome when allegations prove well-founded.
Avoiding Health Care Fraud Moving Forward
The best protection against fraud accusations involves proactive compliance practices that an attorney can assist with establishing:
- Thorough Billing Training & Auditing
Regular staff instruction on accurate coding and claims submission standards with ongoing audits and corrections. - Robust Record-Keeping
Scrupulous patient charts and documentation of all services, clearly backing up each charge submitted. - Compliance Program
Developing an internal system including a designated officer, anonymous reporting, and accountability measures. - Data Analytics
Leveraging analytics similar to those regulators use to self-audit for outlier patterns warranting further review. - Periodic Risk Assessments
Independent reviews keep current on evolving billing rules and schemes while recommending updates where vulnerabilities appear. - Limited Access Controls
Segregating billing, recordkeeping.