Florida Federal Criminal Defense Attorney focusing on the defense of white collar crimes.

What is Healthcare Fraud?

Healthcare fraud is the intentional deception or misrepresentation of healthcare transactions by a provider, employer group, or member for the sake of receiving an unauthorized benefit or financial gain. Individuals convicted of this crime face imprisonment and substantial fines.

Healthcare fraud can be perpetrated by a provider, such as a doctor or therapist, an insured member, or an employer.

What was once regarded as simple billing errors are now routinely pursued as fraud and abuse. As efforts to detect and prosecute healthcare fraud have grown more aggressive, the need for experienced defense counsel has become critical. The difference between a simple billing error, a civil False Claims Act prosecution and criminal indictment often depend upon your attorney's advocacy and representation.

Examples of Provider Healthcare Fraud include:
• Misrepresenting oneself as a licensed healthcare provider
• Kickbacks in return for referring patients or influencing the provision of health care are other common schemes
• Providing services by untrained personnel
• Failing to supervise unlicensed personnel
• Distributing non-approved devices or drugs

Fraudulent billing practices, such as
• Billing for services, procedures and/or supplies that were not provided
• Billing for non-covered services as if they were covered items
• Deliberately billing for duplicate payment for services
• Misrepresentations of dates, descriptions of services, or subscribers/providers
• Providing false employer group and/or group membership information
• Incorrect reporting of diagnoses or procedures to maximize insurance reimbursement
• Performing and billing for medically unnecessary services in order to obtain insurance reimbursement
• Unbundling – charging separately for services that are actually a part of a single procedure
• Fraudulent cost reporting by institutional providers

Examples of Insured Member Healthcare Fraud include:
• Using someone else's coverage or insurance card to obtain healthcare
• Filing claims for services or medications not received
• Forging or altering bills or receipts
• Doctor shopping – going from one physician to another to obtain multiple prescriptions for an controlled substance

Examples of Employer Healthcare Fraud include:
• False portrayal of an employer group to secure healthcare coverage
• Enrolling employees who are not eligible for healthcare coverage
• Changing hire or termination dates to expand dates of coverage
• Creating phony health insurance companies or employee benefit plans.

Medicare Fraud and Medicaid Fraud

Most civil healthcare fraud matters involve the False Claims Act (FCA), under which the federal government may bring civil enforcement actions and seek damages and penalties against providers who knew that false or fraudulent bills were submitted to Medicare, Medicaid, or other federal health programs.

In 1986, when Congress amended the FCA to address fraud against the Medicare and Medicaid programs the intention was for all providers to take responsibility for ensuring the accuracy of the bills they submit for reimbursement. The purpose of the law is to single out those providers who recklessly or with deliberate indifference allow fraudulent billing practices to occur or continue.

Overall, the FCA has powerful and far reaching effects. First, it has been the vehicle for recovering hundreds of millions of dollars of fraudulently obtained funds each year. Second, the statute encourages providers to take responsibility for the accuracy of their claims - because they may be liable under FCA if they are reckless or deliberately ignorant of wrongdoing by employees. Finally, the statute helps to deter providers from committing fraud, because of its damage and penalty provisions.