While many of the fraud investigations launched by the federal government target consumers, there is a growing trend among law enforcement to pursue healthcare providers. It is not hard to understand why: each year the total amount of healthcare fraud is more than $68 billion according to Blue Cross Blue Shield.
Unfortunately, the vigor with which investigators and federal prosecutors have approached these fraud allegations has led to a rush to judgment in some cases. After all, there are few things as complex as healthcare billing. These complexities have led to misunderstandings during the billing process that are wrongly identified as fraud. Many innocent people get swept up in the efforts monitoring Medicare and Medicaid fraud in Houston.
If you are under federal investigation for healthcare fraud, it is important to act decisively. The right defense attorney could help you fight these charges, and in some cases potentially help you avoid being charged in the first place. If you are ready to get started on your defense, speak with attorney Doug Murphy right away.
Understanding Federal Healthcare Fraud in Texas
While Medicare and Medicaid are distinct programs with different recipients, the manner in which fraud affects them is the same. Healthcare fraud can come in many different forms, with some cases differing substantially from others. The theme that ties these acts together is the pursuit of payment from the government for fraudulent medical claims. Common examples of Medicare and Medicaid fraud include:
Submitting False or Fraudulent Claims
One of the most common forms of healthcare fraud is the submission of false or fraudulent claims. These claims can take a variety of forms. This could include creating a claim for services that were never performed at all or were performed by someone else.
Not all claims of fraud involve falsified care. In many cases, healthcare providers profit from performing tests or treatments that are unnecessary. This can also include what is known as “upcoding.” Upcoding involves billing Medicare or Medicaid with the most expensive medical devices or treatments available but providing them with less expensive options. The doctor would then pocket the difference.
Making Duplicate Claims
Double billing is another common form of fraud. This type of fraud is often more deceptive than simply submitting the same claim documentation twice. Often, medical providers will order a battery of tests and submit them all as a single claim. If the provider then submits an additional claim for a single test out of that battery with the intent to defraud Medicaid or Medicare, they could face federal charges.
Manipulating Undercharging Requests
Many providers use the high volume of claims from their office as cover for fraudulent activity. Because of the complexity of billing, it is common for over- or under-billing to occur. Typically, providers will submit a bill when they discover they undercharged. Conversely, the providers are required to return payments when they discover they have overcharged for their services. A common form of fraud involves requesting payment for undercharges but failing to report any overcharges.
The Anti-Kickback Statute prevents acts of self-referral. This form of fraud does not directly involve filing a claim with Medicare or Medicaid. Instead, the fraud occurs by referring a potential patient to a care provider that you have a financial interest in. This could include a family member's medical practice or another provider that you have a kickback agreement with.
Proving Medicare of Medicaid Fraud in Houston, TX
The specific elements of a healthcare fraud case depend on the type of fraud that is alleged. In each case, the federal prosecutor must establish that you have committed that specific type of fraud, whether it is filing fabricate claims or seeking double payment. There are two important elements that the government must meet in each case: knowledge and intent. The absence of these elements can be fatal to the government's case.
First, to be guilty of fraud you must know that the claims you are submitting are fraudulent or otherwise unlawful. This can result from falsifying medical records yourself or knowing someone else has done so. This provision protects someone who has made an honest mistake from prosecution. This mistake could have occurred in the claims process or within the medical records.
In addition to knowledge, the government must also show you had the intent to defraud these federal programs. This concept is similar to having knowledge of fraudulent documentation, but there is an important difference. There are other reasons besides fraud that a person could be motivated to alter records. If a person alters medical records to avoid being fired for breaching a company policy, they may not be guilty of healthcare fraud. Unfortunately for them, there are other criminal statutes that likely apply.
Examples of Medicare & Medicaid Fraud
Examples can provide a better understanding of complex federal crimes. Consider the following examples of Medicare of Medicaid fraud.
Example #1: Kickbacks
Dr. Jones is a primary care physician. While he does not actively practice there, he is also a part-owner of his cousin's surgical center. When Dr. Jones diagnoses an issue that requires surgery, he refers all of his patients to his cousin's surgical center without disclosing the relationship. When his cousin files Medicare claims for these procedures, Dr. Jones shares in the proceeds. Under this example, Dr. Jones is in violation of the Stark Law.
Example #2: Fraud Through Double Billing
Dr. Smith is a primary care physician. A patient comes to see him complaining of stomach pain. He runs a battery of tests to identify what is ailing the patient, including a blood panel. Dr. Smith bills Medicare for the full battery of tests, then intentionally submits a second claim for just the blood panel. Dr. Smith could face charges of healthcare fraud.
Example #3: Double Billing Mistakes
Consider the previous example. Dr. Smith sees the same patient and performs the same battery of tests, including the blood panel. However, he has no intent to defraud Medicare or Medicaid. By accident, he bills for the entire battery of tests then submits a second bill for the blood panel. Dr. Smith is not guilty of fraud. However, that does not mean he will not face charges.
Possible Penalties of Federal Medicare or Medicaid Fraud
There are multiple federal statutes that provide potential criminal liability for healthcare fraud. These penalties differ depending on the specific allegations. The two statutes most commonly used in Medicare and Medicaid fraud prosecutions include:
Healthcare Fraud Statute (18 U.S.C. § 1347). This statute applies to both fraudulent claims as well as false statements made to obtain funds from Medicare or Medicaid. A conviction could result in up to 10 years in prison and a fine of $500,000 or double the amount of the fraud, whichever is higher.
- Anti-Kickback Statute (24 U.S.C. § 1320a–7b). Kickbacks are governed by their own statute. While these penalties are steep, the maximum is lower than the general healthcare fraud statute. A conviction could lead to five years in prison and up to $25,000 in fines.
When it comes to accusations of Medicare or Medicaid fraud, it is understandable if a potential prison sentence dominates your thoughts. It is important to understand that there can also be collateral consequences for a conviction. These consequences typically center around professional licenses.
Doctors, surgeons, and nurses all require a license to practice their chosen profession. The governing bodies that govern these licenses are typically state agencies, and they have a keen interest in allegations of fraud. If you are convicted or plead guilty to a fraud charge, the odds of you losing your medical or nursing license forever are strong.
This aspect of fraud charges is one strong reason why plea bargains are not always in your best interest. While the courts and prosecutors can promise that you will avoid prison or face limited penalties with a guilty plea, they have no power over state regulatory bodies. Your best chance to keep your medical license is to beat the charges against you.
Common Defenses of Medicare & Medicaid Fraud in Texas
There is no guarantee that an accusation of healthcare fraud will result in your conviction. Your attorney could play a major role in this determination by crafting an appropriate defense. The best defense in your case will depend on the facts involved. For some, actively proving an affirmative defense makes sense. In other cases, relying on the federal government's lack of evidence is enough. Some of the common defenses for Medicare or Medicaid fraud charges include:
- Lack of intent
- Lack of evidence
- Unlawful records seizure
- False allegations
Not every defense will work in every case, which makes your selection of a Houston Medicare or Medicaid fraud attorney so important.
Speak with a Houston Medicare and Medicaid Fraud Attorney
When you face federal Medicare or Medicaid fraud charges, the weight of the United States government is against you. That is no reason to feel hopeless, however, Board Certified Criminal Defense Attorney Doug Murphy has taken on the government and won. In many cases, federal prosecutors will move forward with little evidence of guilt. The right defense could see you prevail at trial or even have your charges dismissed entirely. To learn more, schedule a free consultation with the Doug Murphy Law Firm, P.C. as soon as possible.