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Falsely Reporting an Illness or Injury: Healthcare Fraud Charges

Falsely Reporting an Illness or Injury: Healthcare Fraud Charges

Healthcare fraud is a big issue these days, with both federal and state governments cracking down hard on cases involving false claims. But what exactly constitutes healthcare fraud, and what are the potential penalties? This article provides an overview of some common scenarios, defenses, and implications when facing accusations of falsely reporting an illness or injury to obtain healthcare benefits.

What is Healthcare Fraud?

In simple terms, healthcare fraud refers to intentionally deceiving or misrepresenting information to healthcare benefit programs like Medicare or Medicaid. This includes things like billing for services that were never provided, billing for unnecessary services, billing for a more expensive service than what was delivered, or making false statements to get payments or benefits.

Some examples could include:

  • Falsifying medical records to show delivery of care that didn’t happen
  • Billing for medical equipment after returning it
  • Upcharging for services or procedures
  • Hiding pre-existing conditions to obtain coverage
  • Faking an illness to get prescription drugs

As you can see, healthcare fraud encompasses a wide range of activities – any false claim made to receive money or benefits could potentially fall under healthcare fraud statutes.

What are the Penalties for Healthcare Fraud?

The penalties for healthcare fraud can be severe, including both criminal and civil fines. Exact penalties depend on factors like the dollar amount involved and whether the conduct was part of an organized scheme.

Potential criminal penalties may include:

  • Imprisonment – Healthcare fraud involving federal programs like Medicare/Medicaid is a felony with up to 10 years in prison. Cases with losses over $100,000 or involving mass marketing increase sentences up to 20 years.
  • Fines – Criminal fines up to $250,000 for individuals and $500,000 for organizations may apply. These fines increase substantially for healthcare frauds above certain dollar thresholds.
  • Asset forfeiture – Assets purchased with proceeds from healthcare fraud can be seized and forfeited.
  • License revocation – Healthcare providers can lose their licenses and be barred from participating in federal programs.

On the civil side, financial penalties can be severe:

  • Treble damages – Damages equal to 3 times the amount obtained through fraudulent claims.
  • Additional penalties – Civil monetary penalties between $5,500 to $11,000 can apply per false claim.

As you can see, healthcare fraud should not be taken lightly. The financial and professional consequences can be severe. For providers accused of fraud, banning from federal healthcare programs is often viewed as a professional death sentence.

Defenses to Healthcare Fraud Charges

Despite the severity of penalties, there are viable defenses in many healthcare fraud cases. Common defenses include:

  • Lack of intent: Healthcare billing can be extremely complex. In many cases, errors or oversights occur without any intent to defraud. Showing a lack of willfulness or intent can defeat healthcare fraud allegations.
  • Statute of limitations: There are strict time limits governing when healthcare fraud charges must be brought, often 5-6 years. If too much time has passed, charges can be defeated.
  • No false statement: In any fraud case, the prosecution must show falsity – a statement or claim that is untrue. If billing errors or discrepancies occurred, but no affirmatively false claim was made, fraud charges may fail.
  • No materiality: Not every inaccuracy or discrepancy will sustain fraud charges. The false statement must be “material” – something a reasonable person would rely on. Minor errors generally won’t qualify.
  • Lack of knowledge: Healthcare fraud requires knowing the falsity of information provided. Evidence showing the defendant didn’t know billing claims were false or improper can defeat charges.

Many accused of healthcare fraud are well-intentioned professionals who made mistakes. By raising these and other defenses, experienced attorneys can often get charges reduced or avoid criminal prosecution altogether.

The Bottom Line

Healthcare fraud enforcement continues to ramp up with advanced data analytics allowing payors to spot irregularities easier than ever. This means providers and organizations need to take compliance seriously. But even with best practices, billing errors and disputes happen.

If you find yourself accused of healthcare fraud, stay calm and know there are viable defenses. An experienced attorney can evaluate the merits of your case and build an aggressive defense strategy. In many cases, we can resolve these matters civilly or even avoid criminal prosecution entirely.

Every case has unique facts, so assessing potential defenses requires an in-depth review of billing records and an understanding of the complex rules governing healthcare claims. If faced with an audit or investigation, get experienced counsel involved immediately. An ounce of prevention is worth a pound of cure when it comes to fending off healthcare fraud charges.

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