Everything You Need To Know About Healthcare Fraud

Healthcare fraud is a serious crime that costs taxpayers billions of dollars annually. As a result, federal prosecutors have stepped up their efforts to crack down on all types of healthcare fraud.

Dealing with a healthcare fraud case can be very costly financially and professionally.

If you’re accused of healthcare fraud, seek legal help from an experienced healthcare fraud lawyer immediately. An experienced attorney will help you navigate the complex legal process and protect your rights.

Read on to learn more about healthcare fraud. We’ll cover what you can do to protect yourself when accused, the penalties for committing healthcare fraud, and how the government is fighting back against this crime.

What Is Healthcare Fraud?

Healthcare fraud is a white-collar crime occurring when a healthcare professional files healthcare claims dishonestly for financial gain. This could involve billing for services you didn’t render, more expensive services than those you provided, or using false diagnoses to justify treatments.

Common Types Of Healthcare Fraud

The most common types of healthcare fraud are health insurance fraud, medical billing fraud, drug fraud, and snake oil marketing. Here’s a breakdown and examples of each one of them.

Health Insurance And Medical Billing Fraud

Health insurance fraud is misrepresenting yourself or providing false information to an insurance company to receive benefits or coverage you wouldn’t otherwise be eligible for.
Medical billing fraud occurs when you submit false claims to Medicare, Medicaid, or private insurance companies.

Examples of health insurance and medical billing fraud are:

  • Double billing: Billing an insurance company for the same service twice.
  • Upcoding: Billing an insurance company for a more expensive service than what was provided.
  • Unbundling: Breaking down a single procedure into multiple individual processes to bill the insurance company numerous times.
  • Phantom billing: Billing an insurance company for services or supplies you never provided.
  • Bribing for referrals: Paying kickbacks to healthcare providers for patient referrals.
  • Falsifying diagnosis or treatment: Diagnosing a patient with a condition they don’t have or providing unnecessary treatments.
  • Pharmacy fraud: Failing to provide medication that you’ve billed.
  • Billing for excluded providers: Billing an insurance company for services provided by a healthcare provider who isn’t covered by the insurance plan.
  • Overutilization: Ordering more tests or procedures than necessary.
  • Unnecessary services: Billing for services that are not medically necessary.

Drug Fraud

Drug fraud refers to any illegal activity involving prescription drugs.
Examples of drug fraud are:

  • Prescribing unnecessary drugs: Prescribing a patient medication, they don’t need to make a profit.
  • Selling counterfeit drugs: Selling fake drugs that the FDA disapproves of.
  • Billing for more expensive drugs: Billing insurance companies for brand name drugs when you give patients generic drugs.

Snake Oil Marketing

Snake oil marketing is the promotion of fraudulent or unproven medical products.

Examples of snake oil marketing are:

  • Making false claims about a product’s efficacy: Claiming a product can cure a disease when there is no scientific evidence to support this claim.
  • Misrepresenting a product’s ingredients: Failing to disclose that a supplement contains an undeclared ingredient that could harm the consumer.
  • Failing to disclose potential side effects: Not declaring that medication has possible side effects that could harm the patient.

Who Investigates Healthcare Fraud?

Several federal agencies investigate healthcare fraud, including the following:

  • The Department of Health and Human Services-Office of Inspector General
  • Federal Bureau of Investigation
  • Medicaid Fraud Control Units (state and local)
  • Drug Enforcement Administration
  • DOJ Healthcare Fraud Prevention and Enforcement Action Team

Medical fraud cases in New York are investigated and prosecuted by the New York Attorney General and the US Attorney.

The fraud investigations are most often the result of a whistleblower who reported the practitioner to the government.

It could also be from a practitioner’s billing records which defy algorithms regarding the frequency of treatment or excessive writing of prescriptions.

These investigations are conducted by the Department of Health and Human Services Office of Inspector General at the federal level.

Investigations at the State level are often pursued by the Medicaid Fraud Unit of the NY Attorney General’s Office and by healthcare insurers such as United Healthcare.

What Are The Stages Of A Healthcare Fraud Investigation?

Several things happen when an informant or whistleblower provides federal agencies with information about potential healthcare fraud.

The agencies gather evidence to determine if there’s enough probable cause to believe a crime has been committed. If there’s probable cause, the next step is to obtain a search warrant from a judge.

Once they obtain a warrant, federal agents will execute the search warrant and seize any evidence related to the healthcare fraud. The evidence could be anything ranging from billing records to patient medical records.

If they find evidence of healthcare fraud, an attorney from the Healthcare Fraud Strikeforce or a local attorney’s office will present the findings to a grand jury.

The grand jury will then decide whether or not to indict the suspects on healthcare fraud charges. Once the case goes to trial, the defendants have an opportunity to defend themselves against the allegations.

How To Avoid Healthcare Fraud

Here are some tips on how to prevent healthcare fraud:

  • Ensure that you are billing insurance companies correctly and not overcharging for services. Be upfront with patients about what their treatment will cost and get their consent before ordering any tests or procedures.
  • Keep accurate and complete patient records. This includes documenting all treatments, medications, and tests you order for patients.
  • Do not prescribe unnecessary drugs or order unnecessary tests. Only prescribe medication or order tests if it is in the best interest of the patient’s health.

What Are The Penalties For Healthcare Fraud?

You risk jail time or severe penalties if you are convicted of healthcare fraud. The specific penalties you face will depend on the type of healthcare fraud you are accused of and the amount of money involved. Some of the potential penalties that you might encounter are:

  • Fines of up to $250,000 per charge.
  • Jail time of up to 10 years.
  • You may be placed on probation for some time. Conditions of your probation could include paying back the money you defrauded, performing community service, or attending counseling.
  • Loss of your professional license.
  • Loss of board certification.
  • Restitution.

Talk To A Healthcare Fraud Lawyer Before It's Too Late

Suppose you are being investigated for healthcare fraud or have been charged with this crime, partner with us at Birzon & Associates. We are a reputable and experienced firm that deals with healthcare fraud issues.

We’ll review the evidence against you and help you develop a strong defense against the charges. Contact us today to schedule a consultation with one of our healthcare fraud lawyers.