Health Care Fraud Attorney

The healthcare industry, akin to the financial industry, is a sector where public confidence is important. The fact is that the overwhelming majority of healthcare and medical providers are honest, ethical, hard working people. On the other hand, there are also many medical providers who look to inflate the size of their bank accounts at the expense of their patients, insurance providers, and others. In actuality, National Health Care Anti-Fraud Association (NHCAA) reported that the financial losses from health care fraud activity can reach into the tens of billions of dollars every year.

Due to such huge financial losses, the FBI and other federal agents and prosecutors persistently investigate, pursue, and prosecute those who are involved in health care fraud schemes. When looking at the long-term and severe penalties associated with a conviction, alleged offenders need to get in touch with an experienced health care fraud attorney immediately.

What is Health Care Fraud?

At its core, health care fraud is basically the providing of false or misleading information that is used to determine the amount of health care benefits payable. It is categorized as a white-collar crime and, due to the inherent nature of these fraudulent schemes, the perpetrator is able to gain financial wealth by shifting the costs down to customers and insurance providers. This genre of fraud is a widespread problem. It can also be socially and financially ruinous. For this reason, and many others, the FBI, the U.S. Postal Service, and the Office of the Inspector General (OIG) are all charged with the task of investigating health care fraud.

An important characteristic of health care fraud, and part of the reason that federal agents aggressively prosecute it, is the effect of this fraud on insurance policy holders and consumers. Fraud inevitably leads to higher policy premiums, greater out-of-pocket expenses, and lower available benefits and coverage.

DEFENSE TEAM SPOTLIGHT

Todd Spodek

Lead Attorney & Founder

Featured on Netflix's "Inventing Anna," Todd Spodek brings decades of high-stakes criminal defense experience. His aggressive approach has secured dismissals and acquittals in cases others deemed unwinnable.

NY Bar Admitted Multi-State Licensed Federal Courts

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Legal Scenario: What Would You Do?

Scenario

You are a physician who recently received a letter from the Office of Inspector General stating that your billing patterns for certain diagnostic tests are under review. A former employee has reportedly filed a qui tam lawsuit alleging that your practice routinely billed Medicare for comprehensive office visits when only brief consultations were performed.

What kind of legal exposure am I facing, and what should I do before responding to the OIG?

Attorney's Answer

You are potentially facing charges under the False Claims Act (31 U.S.C. § 3729), which carries treble damages and penalties of up to $11,000 per false claim submitted, as well as criminal health care fraud charges under 18 U.S.C. § 1347, which carry up to 10 years in prison per count. Do not respond to the OIG letter, speak with investigators, or alter any billing records before retaining experienced health care fraud defense counsel. An attorney can conduct an internal audit of your billing practices, assess whether a voluntary self-disclosure to the OIG may reduce your exposure, and negotiate on your behalf to prevent criminal referral. Early intervention is critical because cooperation and remedial measures taken before indictment can significantly influence whether prosecutors pursue criminal charges or resolve the matter civilly.

This is general information only. Contact us for advice specific to your situation.

Common Ways Health Care Fraud Occurs

To get a better picture of what constitutes health care fraud, we can study some common examples. Primarily, theft of patient information is among the most prevalent types of health care fraud. In this scenario, the medical providers use patient information to obtain reimbursement for services and goods they never provided. Several ways that criminals carry out this fraud include:

• Providing unlawful incentives, whether its cash or tangible gifts, to lure beneficiaries to to a specific clinic where patient identities are then obtained
• Harvesting patient information at free screenings (such as at health fairs)
• Inducing medical staff to copy patient insurance information and share it with individuals involved in a scheme
• Buying patient information from other individuals involved in the scheme