Healthcare Fraud Defense

The business of healthcare fraud is a lucrative one, costing our country an estimated $80 billion a year, and the federal government has focused considerable attention on identifying and punishing perpetrators of this type of white-collar crime, as well as recovering the considerable amounts of taxpayer dollars taken in commission of the crime. The U.S. Departments of Justice (DOJ) and Health and Human Services (HHS) coordinate both the Medicare Fraud Strike Force, a multi-agency team of federal, state, and local investigators, and the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to combat Medicare fraud.

If you are accused of violation of 18 U.S. Code 1347, entitled Health Care Fraud, you face the possibility of incarceration and fines, and, if you are a healthcare provider, you may face the loss of your right to practice in the medical industry. You need to contact Dan Carman, Lexington healthcare fraud lawyer, because he understands the seriousness of your charges and will work with you to build a strong defense against these charges.

Some Examples of Healthcare Fraud

Fraud can be found throughout the healthcare industry. Both providers and users of health care have been accused of healthcare fraud.

Providers may be accused of committing fraud by:

  • billing for services not actually provided
  • double billing for services
  • billing for a noncovered service as a covered service
  • altering medical records
  • using unlicensed staff
  • prescribing drugs unnecessarily
  • taking kickbacks or bribes for referrals
  • providing services members don’t need.

Users may be accused of committing fraud by:

  • falsifying information
  • forging prescriptions or selling prescription drugs
  • adding an ineligible dependent to their healthcare plan
  • loaning out their insurance card, or using someone else’s
  • committing identity theft.

How Healthcare Fraud is Uncovered

In its fight against healthcare fraud, the Department of Justice depends on employees and others in the healthcare industry to “blow the whistle” when they suspect a healthcare provider or patient of fraud. Federal law provides protection from retaliation to whistleblowers who report suspected Medicare fraud and allows them to receive payment of as much as 30 percent of the fines collected by the government as a result of the informant’s whistleblowing. DOJ reports over $13 billion was collected in civil settlements of fraud cases reported by whistleblowers from 1987 to 2007.

DOJ and HHS’s combined Medicare Fraud Strike Force was also given authority through the Affordable Care Act to enhance screening and enrollment requirements, to share more data across the government, to expand recovery efforts for overpayments, and to have increased oversight of private insurance abuses. A partnership was also recently established by the federal government with state officials, large private health insurance organizations, and other healthcare anti-fraud groups for the purpose of sharing information in the fight against fraud.

Further, advances in data analysis techniques now allow strike force teams to identify levels of high billing in so-called fraud “hot spots,” which in turn can lead to identification of new schemes as well as uncovering existing fraud by persons passing themselves off as healthcare providers or suppliers.

What Can Happen If You’re Convicted of Healthcare Fraud

If you are charged with and convicted of healthcare fraud, federal law allows both civil and criminal penalties for the crime. If you receive a civil penalty, you will be required to pay restitution to the victim(s) for any money you caused them to lose through fraud. A criminal penalty means you can be fined, imprisoned, and ordered to pay restitution.

  • Prison time. If you are found guilty of making a false claim or statement related to a Medicare or Medicaid claim, you face up to 5 years in prison for each offense, and 10 years for each offense if you are convicted of federal healthcare fraud. If someone suffers serious bodily injury due to your fraud, you can be sentenced to up to 20 years, and you face life in prison if someone died as a result of your crime.
  • Fines. If you as an individual are convicted of Medicare or Medicaid fraud, you can be fined up to $250,000 for each offense; if you are in a group that is convicted, the group can be fined up to $500,000 for each offense. Convictions for repeated fraud can results in millions of dollars in fines.
  • Restitution. You may be ordered to make restitution to your victims if you are convicted of healthcare fraud, meaning you must pay back all money you obtained fraudulently—to individuals, insurance companies, or any other entity that suffered financial harm through your criminal activity. Restitution can be ordered in addition to fines.
  • Probation. You may be placed on probation as a result of your conviction. Probation can last from a year up to three years or more. During this time, you will be required to meet with a probation officer, hold down a job, stay away from felons, and generally stay out of trouble. You may also be required to perform community service.

Furthermore, if you are a healthcare provider in Kentucky who is convicted of healthcare fraud, you face suspension or permanent cancellation of your license to practice by the Kentucky Board of Medical Licensure.

What Should You Do If You’re Suspected of Healthcare Fraud?

If you have been approached by federal investigators concerning healthcare fraud in Lexington or elsewhere in Kentucky, your first step should be to contact Dan Carman, Lexington criminal defense lawyer. Dan is admitted to practice law in all courts in Kentucky, in the United States District Courts for the Eastern and Western Districts of Kentucky, and in the Sixth Circuit of the United States Court of Appeals.

He is also a member of the National Trial Lawyers Top 100 Trial Lawyers. Prior to entering private practice, he served as a law clerk to Chief Judge Jennifer B. Coffman in the U.S. District Court in Lexington and as a judge advocate in the United States Marine Corps. He is a veteran of Operation IRAQI FREEDOM.

Contact him today so he can begin work on your healthcare fraud defense. Fill out our online contact form or call (859) 838-1415.