Medicare Fraud + Laws, Charges & Statute of Limitations

What is White-Collar Crime and Healthcare Fraud?

White-collar crime is a nonviolent, financially motivated crime committed by someone working for the government or a business. An example of white-collar crime is healthcare fraud. Healthcare fraud occurs when there is an intentional submission of false information to receive greater financial benefits.

Healthcare is one of the largest industries. The United States spends approximately $2 trillion each year on healthcare. Unfortunately, the United States also spends almost $68 billion each year on healthcare fraud.

Types of Healthcare Fraud

Due to the large industry of healthcare, fraudulent activity has been rampant over the last two decades. As a result, the government has put into action task forces to diligently monitor and handle healthcare fraud. The majority of healthcare fraud occurs with Medicaid and Medicare.

There are many ways in which a business or government professional can perform healthcare fraud. A top culprit is overbilling or billing for services that are non-existent. Another common fraudulent activity is increasing the cost of a medical procedure by billing for each step of the procedure.

Mis-diagnosing or the false diagnosis of a patient in order to receive financial gain is healthcare fraud. When a physician’s office or hospital does not accurately classify a procedure with the purpose of being compensated, they are guilty of healthcare fraud.

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Legal Scenario: What Would You Do?

Scenario

You are a physician who owns a small medical practice, and a billing manager you hired has been submitting claims to Medicare for patient visits that never occurred and for procedures that were never performed. You just discovered the fraudulent billing when a Medicare auditor contacted your office requesting documentation for hundreds of suspicious claims totaling over $2 million.

Can I be held personally liable for the fraudulent Medicare claims even though my billing manager submitted them without my knowledge?

Attorney's Answer

Under federal law, you could face serious exposure even if you did not personally submit the false claims. The False Claims Act (31 U.S.C. § 3729) imposes liability not only for knowingly submitting false claims but also for acting in reckless disregard of their truth, and as the practice owner, prosecutors may argue you had a duty to oversee your billing operations. Criminal charges under the federal healthcare fraud statute (18 U.S.C. § 1347) carry penalties of up to 10 years in prison per count, and the Anti-Kickback Statute (42 U.S.C. § 1320a-7b) may also come into play depending on the circumstances. You need to retain a healthcare fraud defense attorney immediately, preserve all billing records, and avoid making any statements to investigators without counsel present, as the statute of limitations for healthcare fraud is typically six years from the date of the offense.

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

Billing more for a service than what it is worth is called upcoding. Upcoding allows the organization to bill for more money and this is considered healthcare fraud. Kickbacks and incentives for patient referrals or tampering with deductibles and copays are all criminal activities.

Medicare Fraud Laws