You have an enormous amount at stake. Do not risk your professional or personal future attempting to deal with the complexities and legal intricacies of a healthcare fraud case on your own.
Reach out to the team of criminal defense attorneys at Dughi, Hewit & Domalewski. Our skilled legal counsel will put their years of experience to work as they help you navigate your cases and craft the strongest defense possible.
What Is Healthcare Fraud?
Healthcare fraud is a white-collar crime that can occur in many ways. A common type of healthcare fraud involves filing dishonest claims for medical services to earn a profit.
According to the FBI, which conducts these kinds of criminal investigations on a federal level, healthcare fraud wastes tens of billions of dollars every year. Meanwhile, Mastercard Healthcare Solutions notes that as much as 10% of U.S. healthcare claims are estimated to be fraudulent. Healthcare fraud is also heavily investigated by state attorneys general, and charges can be brought for state healthcare fraud or federal healthcare fraud.
This means that the state and federal prosecutors who investigate these crimes take healthcare fraud very seriously, and the punishments for healthcare fraud are accordingly severe.
Types of Healthcare Fraud
Healthcare fraud can take various forms. According to the FBI, three of the more common types of healthcare fraud are:
1. Healthcare Fraud Committed by Medical Providers
- Phantom billing happens when providers bill for a service the patient never actually received.
- Double billing occurs when providers submit two or more claims to a patient’s insurance company for the same service.
- Unbundling occurs when providers submit two or more bills for the same service.
- Upcoding involves billing for a service that costs more than the service the patient received.
- Prescriptions (see below)
2. Healthcare Fraud Committed by Patients and Others
- Bogus marketing occurs when someone convinces another person to share their health insurance information (such as their ID number) to bill for medical services they never received or enroll the person in a fake benefit plan.
- Impersonation of a healthcare professional involves providing and/or billing for healthcare-related services without being licensed to do so.
- Identity theft happens when someone uses another person’s health insurance without their permission.
- Identity swapping is when someone allows another person to use their insurance.
- Prescriptions (see below)
3. Healthcare Fraud Related to Prescriptions
- Forgery of prescriptions includes creating fake or unauthorized prescriptions themselves as well as using prescriptions you know to be forged.
- Diversion refers to the process of “diverting” legal prescriptions for non-legal uses, including selling prescriptions.
- Doctor shopping is the process of intentionally visiting numerous medical providers in an effort to get prescriptions for controlled prescription medications (e.g., painkillers).
Healthcare Fraud and the Anti-Kickback Statute
There are some industries in which it is legal and even normalized to incentivize referrals by providing material rewards to those who refer new customers to your business. However, according to the HHS, it is illegal to pay for referrals in federal healthcare programs (including Medicare and Medicaid).
The Anti-Kickback Statute (or AKS) [42 U.S.C. § 1320a-7b(b)] is an anti-fraud statute outlawing the provision of rewards for patient referrals as well as for generating business for any item or service from the Federal healthcare programs (e.g., billing for Medicare and Medicaid services, drugs, and supplies).
Legal Consequences for Healthcare Fraud
In the U.S., healthcare fraud carries severe legal consequences. Those convicted of healthcare fraud can face significant fines reaching into the millions of dollars depending on the scale and severity of the fraud. Those found guilty can also face lengthy prison terms.
Being convicted of healthcare fraud can ruin a provider’s professional reputation and career. A healthcare fraud conviction can lead providers to be permanently excluded from participating in federal healthcare programs like Medicare and Medicaid. A medical provider might even have their license permanently revoked as a punishment if convicted.
Possible Defense Strategies Against Healthcare Fraud Charges
When confronted with such allegations, it is crucial to understand the available legal defenses that can protect the accused’s rights and reputation.
Some common strategies include:
- Insufficient evidence
- Lack of intent
- Entrapment
- Compliance with healthcare laws/regulations
- Mistaken identity
- Lack of knowledge or awareness
- Statute of limitations
Your healthcare fraud defense attorney can advise you on which strategy or strategies will help you meet your goals, whether it is mitigating penalties, pursuing a dismissal of the case, or being acquitted of charges. They will closely examine the evidence against you and build a strong defense tailored to your case.
How to Choose the Right Healthcare Fraud Defense Attorney
Working with the right healthcare fraud defense attorney is the most important thing you can do right now to safeguard your rights, your career, and achieve a successful outcome.
You should begin by seeking out attorneys with specific experience in healthcare fraud cases, with a track record of successfully defending their clients from charges of healthcare fraud. Your ideal attorneys will also be those with an in-depth understanding of healthcare laws and regulations and who have experience dealing directly with government agencies like the FBI, Department of Justice (DOJ), and the Office of Inspector General (OIG).
Besides experience with healthcare fraud defense and a demonstrated record of success in this field, you will also want to weigh more subjective factors like the attorney’s reputation within their local community, their communication style, and their approach to representation.
By considering these factors carefully, you can choose a healthcare fraud defense attorney with the skills and knowledge to protect your interests and provide guidance throughout the legal process.
Consult With an Experienced Healthcare Fraud Defense Attorney
The support of qualified attorneys—experienced in criminal law plus the specific area of healthcare fraud defense—can mean the difference between significant fines or prison time and protecting your future.
At Dughi, Hewit & Domalewski, our knowledgeable healthcare fraud defense attorneys are committed to vigorously defending your rights and ensuring you receive the most effective representation possible. We understand the gravity of the situation and the impact it can have on your career and reputation.
Contact us today to discuss your case and learn how we can help you fight back.
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