The Basics of Healthcare Fraud

Healthcare fraud is considered a white collar crime, and charges are typically brought against doctors and healthcare organizations. Due to the complexity of the healthcare industry, it can be hard to detect and difficult to prove. As a result, allegations can be made even when no fraud occurred or there was no intent to commit fraud. If you’re facing charges for healthcare fraud, it’s imperative that you seek legal counsel to make sure you get the best possible result. 

Knoxville criminal defense attorney John Barnes and former federal prosecutor Ed Holt represent those who have been accused of healthcare fraud to make sure their rights are protected. If you would like a free consultation and case evaluation, call us at 865-805-5703 or send us an emailtoday.

Who You Are Up Against

If you’re facing charges for healthcare fraud, it’s important to understand who the parties are. The “victims” of the alleged healthcare fraud are the insurance providers, which are usually national corporations that serve multiple states. As a result, healthcare fraud cases are typically handled by the federal government and investigated by the Office of the Inspector General from the Department of Health and Human Services, often in concert with the Tennessee Bureau of Investigation. 

Healthcare fraud isn’t limited to just private insurance companies, however. Charges for healthcare fraud can also be brought on behalf of Medicare and Medicaid, federal insurance programs with specific laws that govern healthcare fraud claims. Most claims for healthcare fraud include fraud against both private insurance providers and either Medicaid, Medicare, or both. 

Common Healthcare Fraud Allegations

Healthcare fraud typically occurs when medical providers or patients abuse the healthcare system for their own financial benefit. Given the complex relationship between healthcare providers and the insurance industry, healthcare fraud can occur in a variety of circumstances and situations. Here are some of the common healthcare fraud allegations that we see:

  • Accepting kickbacks or other financial benefits for patient referrals
  • Falsifying medical records or diagnoses in order to bill for unnecessary tests, surgeries, or other procedures
  • Performing unnecessary procedures or providing unnecessary services for the purpose of increasing billings
  • Billing for procedures or services that were never performed or provided
  • Using a patient’s identity or creating a false identity to bill for services or procedures that were never performed
  • “Upcoding” – billing for services or procedures that are more expensive than what is medically necessary
  • “Unbundling” – billing for each step of a procedure as if each were a separate procedure
  • Billing non-covered services, procedures, or other treatments as covered treatments
  • Waiving patient co-pays or deductibles and then overbilling the insurance provider to recover the loss
  • Billing patients for amounts that were covered by the insurance provider

The practices above are typically committed by people in the healthcare industry, but individuals can also be accused of healthcare fraud in the following scenarios:

  • Providing false information in order to obtain insurance coverage
  • Adding someone to your insurance coverage by providing false information
  • Exaggerating a claim
  • Visiting different doctors in order to obtain multiple prescriptions
  • Using someone else’s insurance

Healthcare fraud is extremely complicated, and it may be difficult to understand what exactly the government is claiming that you did wrong. No matter what the circumstances are surrounding your case, it’s critical that you hire a defense attorney as soon as possible.  

Consequences You May Be Facing

Healthcare fraud is a serious crime, punishable under federal law. If convicted, you may be facing both civil and criminal sanctions. In addition, it’s important to realize that each alleged act of fraud can be charged as a separate offense, meaning that the consequences can quickly add up. 

Healthcare fraud can result in lengthy prison sentences. A conviction for a single charge of Medicare or Medicaid fraud can result in five years in prison. Convictions for other types of healthcare fraud can carry a sentence of up to 10 years in prison. If the alleged fraud resulted in bodily injury or death, you may be facing a sentence of twenty years to life in prison.

On top of a prison sentence, you may also be facing harsh fines. Medicare and Medicaid fraud is punishable by fines of up to $250,000 for individual healthcare providers, while healthcare organizations face fines up to $500,000. And again, these fines can be imposed for each count of healthcare fraud. 

In addition to the fines, you may be subject to restitution if you are convicted. This means that you may be ordered to pay back any funds that were obtained as a result of the alleged fraud. 

While no one wants to go to prison, the fines and restitution can also be a significant burden. If you are convicted of healthcare fraud, you may be required to sell your home and other assets in order to pay these amounts. 

Lastly, a conviction for healthcare fraud may require you to serve a probation sentence. While probation is preferable to time in prison, the probation system can be onerous, requiring you to comply with various specific conditions and serve your time under close supervision.  

Defending Yourself Against Healthcare Fraud Charges

If you’ve been charged with healthcare fraud, you can’t afford to lose hope. The prosecution wants you to believe that the evidence is overwhelming and your conviction is a certainty. However, they have to prove the charges against you, and you have the opportunity to challenge the evidence, examine their witnesses, and argue for a fair result. Most importantly, don’t think that by pleading guilty that you’ll definitely get a more favorable outcome. It’s critical to hire a skilled criminal defense attorney to help you formulate the best possible defense. 

Most defenses to healthcare fraud focus on the element of intent. You can’t accidentally commit fraud – you have to have mean to do it – otherwise known as having intent. As a result, you may be successful if you can argue that you lacked the intent to commit fraud. Your attorney can help you assemble the evidence to demonstrate that the alleged fraud was the result poor management or negligent business practices. 

Contact a Tennessee Healthcare Fraud Defense Attorney

Healthcare fraud is a very serious crime with severe consequences that can change your life forever. The law is complicated and virtually impossible for non-lawyers to navigate successfully. If you’ve been charged with healthcare fraud, contact Barnes Law for help. We bring experience, skill, and dedication to our clients to ensure a fair result. Call us at 865-805-5703 or send us an emailin order to schedule a free consultation. 

Leave a Reply

Your email address will not be published. Required fields are marked *