What Is Healthcare Fraud? A New York Defense Attorney Explains
In the United States, national expenditures on health care exceed $3 trillion annually. Spending in the health care sector continues to outpace inflation. Some of the costs associated with health care expenditures are driven by fraudulent claims, and the federal government takes health care fraud allegations seriously because of the cost to taxpayers and patients. Fraud may occur against patients, private insurers, or federal programs including Medicaid, Medicare, and Tricare. Whenever fraud occurs, and no matter who the alleged victim, defendants involved in fraud schemes can face criminal charges and civil actions to recover funds obtained through involvement with health care scams.
If you are accused of healthcare fraud, you could find yourself facing frozen financial accounts, and seizure of money and assets that were believed to have been illegally obtained. You could be named as a defendant in a civil lawsuit and could lose your license to provide care services. You could also face prosecution on the state level or the federal level, with indictments for charges that could potentially result in large fines and lengthy periods of incarceration. Protecting your financial security, freedom, career, and reputation requires prompt, aggressive, and strategic action. You need a New York defense attorney who can help you to respond appropriately to the claims made against you and who can assist with developing an effective overall legal strategy to resolve all accusations as quickly as possible with no penalties or minimum consequences.
Bukh Law Firms, PLLC represents doctors; pharmacists; drug company employees and executives; drug sales reps; pharmaceutical manufacturers and distributors; manufacturers and suppliers of medical devices; pharmacy benefits managers; and others within the healthcare industry. When you work in the healthcare field and are accused of fraud, contact our legal team right away so we can start representing your interests.
What is Healthcare Fraud?
Healthcare fraud involves a variety of behaviors in connection with the provision of medical services or in connection with billing for medical services. Examples of fraud including making false statements, making material misstatements, omitting pertinent information, or engaging in prohibited actions considered to be a dishonest attempt to obtain money or assets. Examples of healthcare fraud include:
- Hospital Fraud: Hospital fraud occurs when hospitals unnecessarily admit patients, bill health insurers for unnecessary services, or perform services that are not medically necessary for purposes of billing health insurance providers.
- Home Healthcare Services Fraud: Medicare and certain other insurers provide coverage for eligible patients to receive certain medical services in their own homes. Home health agencies, however, may commit fraud by billing for home health services for ineligible patients; by manipulating assessment forms so more serious diagnoses are received; or by paying or receiving illegal kickbacks for patient referrals.
- Durable Medical Equipment Fraud: Hospital beds, home oxygen equipment, mobility scooters, and other reusable medical equipment is considered durable medical equipment (DME). Fraud in the durable medical equipment market includes suppliers promising patients free equipment but billing Medicare; unnecessary prescribing of durable medical equipment; doctors charging insurers for DME not actually provided to patients; and billing for more costly products than were necessary or than were provided.
- Medical Device Fraud: Medical device fraud occurs when devices are marketed for non-FDA approved purchases; when knowingly defective devices are sold; or when device manufacturers pay kickbacks to doctors for recommending medical devices.
- Coding Fraud: Coding fraud includes upcoding (billing for services more costly than the services performed); unbundling (billing separately for health services that should be packaged); and coding for non-confirmed diagnoses.
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- Lab Services Fraud: Lab services fraud occur when insurers are billed for lab work that was not necessary or not provided; when labs unbundle groups of tests and bill separately for each to recover more compensation; and when labs pay kickbacks to doctors for patient referrals.
- Medically Unnecessary Services Fraud: This type of fraud occurs when doctors provide, or bill for, services which are not medically necessary.
- Anti-Kickback Act Fraud: Kickbacks are payments for patient referrals. It is illegal to offer, accept, or solicit any kickbacks in relation to recommending or providing healthcare services.
- Stark Act Fraud: The Stark Law prohibits from physicians referring patients for services to any entity the physician has a financial relationship with, if the services will be paid for by Medicaid or Medicare.
- Medical Fraud: Assorted other types of medical fraud may also occur as well, when any care provider makes, or causes to be made, false or misleading statements in connection with claims made to health insurance providers.
Care providers have a professional duty to provide appropriate care to patients, and to be honest in billing patients, private insurers, and government health insurance programs. Engaging in any fraudulent behavior can have grave consequences.
Penalties for Health Care Fraud
The Health Care Fraud and Abuse Control Program was established as a result of a legislative requirement imposed in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose of the Health Care Fraud and Abuse Control Program (HCFAC) was to prevent fraud against both public and private health plans. The program is under the joint direction of the Secretary of Health and Human Service (HHS) and the Attorney General of the United States. Under the program, federal, state, and local law enforcement efforts are coordinated to combat health care fraud. According to the Department of Justice, more than $27.8 billion has been returned to the Medicare Trust fund as a result of the efforts of the HCFAC.
Because federal authorities are involved in combatting health care fraud, investigations into fraud schemes are generally conducted by the Federal Bureau of Investigation (FBI). Defendants can face a wide variety of federal civil and criminal penalties including charges or civil claims under:
- 42 U.S. Code Section 1320a-7a, which imposes $10,000 in fines for each instance of improper claims for health insurance payments.
- 42 U.S. Code Section 1320a-7B, which imposes a maximum sentence of five years imprisonment for false statements or material misrepresentation made in claims for payments under federal health care programs.
- 18 U.S.C. Section 1347, which imposes up to 10 years in prison for willfully participating in any scheme to defraud a health insurer in connection with payments or healthcare benefits.
- 18 U.S.C. Section 1035: which imposes a penalty of a maximum of five years in prison for making any false statements connected with delivering health care services or care benefits.
How a New York Defense Attorney Can Help
A New York defense attorney at Bukh Law Firms, PLLC can provide help to defendants who are facing criminal and civil actions for any type of health care fraud. Let us bring our extensive experience and knowledge of federal and state healthcare law to your case. Call today to learn how we can represent you.