Understanding Healthcare Fraud

The already complicated American healthcare system becomes more complicated each year. From federal billing regulations to private insurance contracts, most healthcare providers must pay professionals to navigate this system. Sometimes, criminal organizations routinely utilize patient information to overbill insurance companies or bill for procedures never performed. This is traditional healthcare fraud, but not all criminalized healthcare fraud is meant to line doctors’ pockets. Certain fraudulent billing practices, such as waiving co-pays or billing to cover otherwise uncovered procedures, are often intended to help poor patients navigate a corrupt private healthcare system. While this is still illegal, many providers charged with healthcare fraud didn’t have malicious financial intent.

The experienced Knoxville healthcare fraud defense attorneys at Barnes Law can help you understand criminal healthcare fraud charges and analyze your best defense. Whether this involves negotiating with prosecutors, fighting to exclude illegally obtained evidence, or pleading your case before a jury, we know that your situation is unique. To schedule your free, confidential healthcare fraud defense consultation, call Tennessee criminal defense attorney John Barnes at his Knoxville office today at (865) 805-5703 or contact us online.

Overview of Federal Criminal Healthcare Fraud Laws

It’s important to distinguish civil healthcare fraud lawsuits under the federal False Claims Act from a criminal indictment for healthcare fraud. If you’re sued for making false healthcare claims, it means the government is seeking to impose monetary damages only. This means they want their money back and then some. A criminal indictment for healthcare fraud, however, means that you’re subject to felony charges that may result in prison, fines, restitution, and loss of your healthcare license.

Federal law criminalizes healthcare fraud under 18 U.S.C. § 1347. If you’ve been charged under this statute, you’ve been accused of the following:

  • executing or attempting to execute,
  • a “scheme or artifice,”
  • to defraud a public or private insurance company, or
  • falsely obtain money from an insurance company.

You need not know your actions were illegal. As long as you knowingly executed a system likely to result in obtaining unearned insurance funds, you may be charged with criminal healthcare fraud. This statute protects both public, Medicare and Medicaid, and private, i.e., Aetna, health insurance companies. As long as the company provides services in multiple states, you may be charged with federal healthcare fraud.

Other types of criminal healthcare fraud include offering illegal “kickbacks” for the referral of Medicare or Medicaid patients. For example, offering a masseuse 10% of all profits from Medicare patients her or she refers is criminalized under the federal anti-kickback statutes. Offering anything of value in exchange for patient referrals, including free healthcare services or expensive meals, is criminal under this statute. The federal government makes clear that, even though such tactics are both legal and common in certain industries, they are criminal in the healthcare field. There are, however, certain important exceptions to this statute. This includes waiving co-pays for poor patients or providing free services if you’ve independently determined a patient cannot afford healthcare. A criminal defense attorney familiar with anti-kickback healthcare exceptions may be able to argue you’re entitled to these protections.

The Most Common Types of Healthcare Fraud

According to the National Healthcare Anti-Fraud Association, the following are the most common forms of healthcare fraud in the United States:

  • Inflation of diagnosis codes to “upbill” for procedurals actually performed. For example, billing for a “medically necessary” 3-D sonogram when the patient actually had a traditional sonogram.
  • Billing for services never rendered. This can include stealing patient information to create false bills or padding legitimate claims with procedures never performed.
  • Misrepresenting the medical necessity of a procedure in order to get it covered. This commonly occurs with plastic surgery, i.e., representing that the patient needs cosmetic injections for “migraines” when they are really cosmetic.
  • Performing medically unnecessary services for the purpose of billing.
  • Altering or falsifying a patient’s diagnosis codes to get certain services covered.
  • Overbilling procedures by charging each step as a separate procedure. For example, charging for a surgical incision, stitches, and appendix removal when the proper charge is for a single appendectomy.
  • Overbilling patients for services covered by an insurance contract, and
  • Waiving patient co-pays or deductibles and then falsely billing an insurance company to make up the difference.

Some medical providers and billing companies may engage in these tactics unaware that they constitute federal healthcare fraud. In such cases, an experienced healthcare fraud defense attorney may argue that you should face only civil penalties.

Criminal Penalties for Healthcare Fraud

Every count of federal healthcare fraud is punishable by up to 10 years in prison. However, if the fraud involved performing non-medically necessary services through deceit and the procedure results in serious bodily injury or death, the provider may be imprisoned for life. Similar penalties apply to providing or taking kickbacks, and your potential prison sentence depends on a number of factors including:

  • Whether the fraud was part of an established criminal scheme,
  • The intent of the parties, i.e., to help a poor patient or buy a summer home,
  • The number of charges, and
  • Your criminal history.

Most convicted defendants will also face fines, probation, and must repay illegally obtained funds.

Defenses to Federal Healthcare Fraud Charges

There are certain exceptions to healthcare fraud, such as investigating and waiving co-pays for Medicare patients in need. An experienced Tennessee healthcare fraud defense attorney may begin his investigation by reviewing the law for applicable exceptions. Further, while lack of fraudulent intent is not a defense to healthcare fraud, intent often plays a roll in the analysis. Providers without pure criminal or financial intent may face lesser fines and penalties or have criminal charges dropped in favor of civil penalties.

Contact a Qualified Knoxville Healthcare Fraud Defense Attorney Today

Healthcare is extremely expensive in the United States, and frustrated providers may tire of begging for payment or watching needy patients struggle to get services covered. At Barnes Law, our healthcare fraud criminal defense attorneys want to hear your story. The sooner you speak with one of our experienced healthcare defense attorneys, the greater the likelihood we can protect your interests. To schedule your free, confidential criminal defense consultation, call attorney John Barnes at his Knoxville office today at (865) 805-5703 or contact us online.