How Attorneys Fight Fraudulent Healthcare Marketing Schemes
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How Attorneys Fight Fraudulent Healthcare Marketing Schemes
Healthcare fraud is a serious issue that costs taxpayers and patients billions of dollars each year. From pharmaceutical companies promoting off-label drug uses to providers billing for services never rendered, healthcare fraud takes many forms.To combat this, attorneys have an important role in investigating fraudulent schemes and holding perpetrators accountable. This article explores common types of healthcare fraud, laws used to prosecute it, building a case, and outcomes for those found guilty.
Common Types of Healthcare Fraud
Some of the most common fraudulent schemes attorneys encounter include:
Pharmaceutical Marketing Fraud
- Promoting off-label drug uses not approved by the FDA
- Inflating average wholesale drug prices to increase reimbursements
- Providing illegal kickbacks to physicians to incentivize prescribing
Medical Equipment Fraud
- Billing for unnecessary medical devices or equipment
- Billing for equipment never provided
Treatment and Testing Fraud
- Billing for services never performed
- Performing and billing for unnecessary or excessive services
- Upcoding services (billing for more expensive services than provided)
Identity Theft
- Using a patient or provider’s insurance information to obtain healthcare services
- Creating fake provider credentials to file claims
Laws Used to Prosecute Healthcare Fraud
Attorneys rely on both criminal and civil statutes to build cases against healthcare fraud, including:
- False Claims Act (FCA) – Imposes civil liability and penalties for knowingly submitting false claims. Also allows whistleblowers to file qui tam lawsuits.
- Anti-Kickback Statute – Criminalizes receiving or paying remunerations to induce referrals of federal healthcare program business.
- Stark Law – Prohibits physician self-referrals for designated health services to entities they or their family members have a financial interest in.
- Health Insurance Portability and Accountability Act (HIPAA) – Providers can face criminal penalties for wrongfully accessing or disclosing protected health information.
Violating these statutes can result in civil monetary penalties, criminal fines, imprisonment, and exclusion from federal healthcare programs.
Building a Fraud Case
From whistleblower complaints to proactive data analysis, cases originate from many sources. Attorneys must then investigate allegations through:
Interviews – Speak with whistleblowers, witnesses, and targets to understand all perspectives.
Data Analysis – Review billing records, medical charts, documentation, etc. to identify trends indicating fraud.
Undercover Operations – Have investigators pose as patients to record fraudulent activities firsthand.
Search Warrants – If evidence suggests criminal intent, obtain warrants to search property and seize further evidence.After thoroughly investigating, attorneys decide whether civil or criminal charges are appropriate. They continue gathering evidence until they have enough to prove violations “beyond a reasonable doubt”.
Outcomes for the Guilty
The outcomes for those found guilty depend on whether the attorney pursues civil or criminal charges.
Civil Remedies
Those found civilly liable under the FCA or other laws may face:
- Treble (triple) damages
- Substantial civil monetary penalties per fraudulent claim
- Potential exclusion from federal healthcare programs
Criminal Penalties
For criminal fraud convictions, possible sentences include:
- Imprisonment – Up to 10 years per count for healthcare fraud
- Fines – For individuals, up to $250,000 per count
- Asset forfeiture
- Exclusion from federal healthcare programs
Attorneys also coordinate with regulators to impose disciplinary actions against licenses and credentials.
The Bottom Line
Healthcare fraud diverts billions from patient care and taxpayers each year. Attorneys play a crucial role in holding perpetrators accountable and protecting patients and federal healthcare programs from further exploitation.
Through whistleblower complaints, data analysis, and thorough investigations, attorneys build convincing fraud cases. They determine whether civil or criminal charges are most appropriate based on the intent, scale and nature of the violations.
For those found guilty, the outcomes can be severe, including steep civil monetary penalties and fines, imprisonment, and permanent exclusion from federal healthcare programs. Prosecuting fraudulent schemes delivers justice while deterring other bad actors.