What to Do When You Are Accused of Healthcare Fraud

An accusation of healthcare fraud brought against you can be frightening, stressful, and lead to uncertainty about your future. Fraud cases that result in criminal charges can damage your professional and personal reputation even if you are proven innocent, and in worst case scenarios can even lead to significant prison time and monetary penalties if you are found guilty. You could face fines or seizure of assets, such as your home, property, or bank accounts.

Healthcare fraud cases often involve significant sums of money, and if you find yourself the target of any government investigation alleging healthcare fraud, you need a lawyer to get involved immediately.

New Jersey criminal defense attorneys understand your rights and can help you fight for your freedom when faced with the threat of a healthcare fraud investigation.

What is healthcare fraud?

Healthcare fraud charges can take many forms, according to the FBI. Billions of dollars a year are lost due to healthcare fraud in the United States.

Doctors, other individuals employed with a medical practice or in the medical field, and even patients themselves, may find themselves accused of healthcare fraud for:

Forged prescriptions
Re-selling prescription medication
Using someone else’s health insurance
Billing for services not received or billing for the same service many times
Enrolling patients in a fake plan
Kickbacks for referrals to a provider
Upcoding, or submitting codes to insurers for more serious or more expensive diagnoses or procedures than diagnosed or performed

These are just a few examples of healthcare fraud allegations; these charges can be nuanced, which is why you need a lawyer who specializes in healthcare fraud investigations.

What laws apply to healthcare fraud in New Jersey?

There are numerous federal and state laws that apply to healthcare fraud in New Jersey.

Some key federal laws that deal with the issue are:

The False Claims Act
The Anti-Kickback Statute
Physician Self-Referral Law
Exclusion Statute
Civil Monetary Penalties Law

At the state level, N.J.S.A. 2C:21-4.3 is the primary legislation that applies to healthcare fraud. It differentiates the types of fraud into four different categories:

2C:21-4.3a applies to a doctor, nurse, or other healthcare practitioner who knowingly commits healthcare fraud.
2C:21-4.3b applies to a doctor, nurse, or other healthcare practitioner who recklessly commits healthcare fraud.
2C:21-4.3c applies to someone who is not in the healthcare field but knowingly commits healthcare fraud.
2C:21-4.3d applies to someone who is not in the healthcare field but recklessly commits healthcare fraud.

There are also state laws criminalizing prescription fraud and destruction, falsification or alteration of records relating to medical care. These laws can be complex to navigate, and different jurisdictions may be more or less favorable to defendants in these types of cases. This is why it is critical to hire a defense attorney familiar with both federal and New Jersey law who understands healthcare fraud and knows how to apply the appropriate defense strategies to your situation.

What entity investigates healthcare fraud?

Depending on the type of alleged healthcare fraud and the individuals involved, different entities may be involved in the investigation.

At the federal level, the following agencies may play a role:

Department of Health and Human Services
Department of Justice
Federal Bureau of Investigations
National Insurance Crime Bureau
Coalition Against Insurance Fraud
National Association of Insurance Commissioners

State and local entities may participate in healthcare fraud investigations, particularly if the alleged fraud involves Medicaid. Private insurers may also conduct their own investigations and make referrals to criminal agencies.

Steps to take if accused of healthcare fraud

If a healthcare fraud accusation has been leveled at you, it can be hard to avoid panicking. The stakes are very high for both healthcare practitioners and their practice, as well as patients.

If you are a medical professional, the last thing you want to have to do is surrender your medical license. Even if you are found innocent, these investigations can affect your future employment if not handled appropriately. You may also be subject to civil lawsuits in addition to criminal charges, with significant financial implications.

Here are some key steps to take upon being notified of any investigation:

Hire a criminal defense attorney, and do not speak to law enforcement officers until you have consulted him or her.
Make sure you understand clearly the exact charges against you.
Begin gathering all records or documents proving your innocence, which may include things like canceled checks, billing invoices, emails, etc.

The more evidence you can turn over to your attorney, the better he or she can defend you. It is important not to destroy anything—tampering or destruction of evidence can result in further charges.

What are the penalties for healthcare fraud?

Penalties for healthcare fraud can be severe.

In NJ, crimes are graded, and the penalties for second, third, and fourth degrees vary. Even a non-healthcare professional who commits a second-degree crime may go to prison for five to ten years, and if convicted of a fourth-degree crime, can find themself spending up to 18 months in prison. Imprisonment in federal healthcare fraud cases is often sought by the government.

Aside from imprisonment, fines, and other punishments, the FBI may use asset forfeiture to punish wrongdoers. Your family may suffer if your assets are seized. If you are a doctor or other medical professional, you could lose your license and be unable to practice medicine again.

There are three kinds of asset forfeiture: criminal, civil judicial, and administrative.

Criminal forfeiture: Your personal property is seized as part of the criminal case against you. It involves property used in the crime or derived from it. You can contest it through the court.
Civil judicial forfeiture: These are actions filed against the property itself, not against you personally. They can be contested through the court. The government has to prove that the property facilitated the crimes or represented criminal proceeds.
Administrative forfeiture: This often involves uncontested seizure and doesn’t usually include real property or houses. It typically includes merchandise, anything associated with a controlled substance, or anything worth less than $500,000. When contested, the government must turn to either civil or criminal forfeiture.

Consult with a knowledgeable healthcare fraud attorney

Working with qualified attorneys who are experienced in the specific area of healthcare fraud defense is one of the most important steps you can take to protect your future and minimize the risk of serious consequences.

At Dughi, Hewit & Domalewski, our healthcare fraud defense attorneys will vigorously defend your rights. We understand the grave impact these charges can have on your career, reputation, and family.

Contact Us Today!