Federal Crime of the Week – Healthcare Fraud

Federal healthcare fraud is the intentional misstatement of facts involving healthcare transactions that leads to unfair and unauthorized benefits or financial gain.  Generally considered a white collar federal offense, this crime can be committed by healthcare providers such as doctors or therapists, nurses, hospital administrators and employees, but can also be committed by insured members or employers.  The federal government has become increasingly more active in prosecuting these types of crimes, and the penalties (fines, incarceration, etc.) are severe.

Even small billing errors are looked at with increasing scrutiny, and sometimes prosecuted as fraud and abuse.  A good lawyer that is familiar with white collar criminal defense can sometimes mean the difference between a federal indictment, or business continuing on.

What are some examples of healthcare fraud?

  • Misstatement of Services Rendered – billing for services that may have never been given; billing for non-covered services; misrepresentation of dates, descriptions, or personnel involved in the treatment; improper coding; billing for medically unnecessary services; “unbundling,” which is charging Medicare separately for services that are actually a part of a single procedure
  • Kickbacks – in return for referring patients or bribery for recommending one plan over another
  • Unreasonable rates – everyone knows that medical services are expensive, but when the charges get out of hand it can literally be criminal
  • Personnel issues – providing and billing for services by unlicensed personnel, or failing to supervise untrained personnel

How can a patient get into trouble for healthcare fraud?

  • Identity issues – using someone else’s Medicare card to get healthcare or prescriptions, or forging names to get coverage for friends
  • Filing fraudulent claims – for services not received
  • Doctor shopping – requesting care, or prescriptions, from multiple doctors at once without efforts to coordinate the care.  Usually stems from a reliance on prescription drugs.  Google “Corey Haim Doctor Shopping” for information on how this child actor from the 1980s destroyed his life going from doctor to doctor for drugs.

Title 18, Section 1347 of the United States Code is the main healthcare fraud statute, and states:

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program,

in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.

Numerous other federal statutes may apply, and Mississippi has laws prohibiting certain conduct relating to healthcare as well.  If you are caught up in a federal healthcare investigation, you will need an attorney helping you, and the sooner the better.  Clarence has experience helping people in these situations, and will be glad to discuss your case with you.  Call at any time, or send an email to clarence@guthriefirm.com and it will go straight to him.