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What Is Health Care Fraud?

Health care fraud takes place when an individual or entity defrauds a health care system. It is an extremely broad category of crime with several ways it can take place, from the forwarding of bills for services never rendered (eg. phantom billing) to actual abuse and neglect of patients under the care/coverage of an existing program, such as an elderly person being mistreated or not given prescribed medication or diet by care assistants charged with doing so.

Types of Health Care Fraud

Health care fraud involving Medicaid, a social program created to help serve the economically disadvantaged in seeking health care coverage, commonly pertains to double billing, kickback schemes, and filing claims for reimbursement which are not within the scope of the program (eg. filed medical claims by an ineligible person or provider). Because of the vulnerable position of many Medicaid recipients, patients may be more susceptible to manipulation or coercion from providers engaging in health care fraud or may be desperate enough to engage in fraudulent behavior themselves.

Medicare fraud is equally rife with fraudulent behavior, from billing for no-shows and unnecessary tests and procedures to issues of identity theft in order to unlawfully gain coverage or submit false claims. Given that Medicare primarily covers the elderly as well as those with permanent disabilities, the opportunity to subject patients to a battery of unnecessary tests, or to bill for unnecessary equipment (mobility aids, etc.) is quite attractive to potential fraudsters.

Health care fraud is a serious crime and it takes many forms, including:

  • Submitting exaggerated or erroneous claims for health care services
  • Prescribing unneeded medications or treatments
  • Modifying medical records
  • Accepting kickbacks
  • Providing false information when applying for programs or services
  • Using unlicensed staff

Health Care Fraud Penalties

False claims, false statements and health care fraud can lead to penalties ranging from five years imprisonment to life behind bars for participating in defrauding the system, or patients within it.

At the state level, charges involving health care fraud are almost always classified as felonies (though some states do separate these felony charges by degree, based on the sum cost of the alleged defrauding), and penalties range from 5 to 15 years imprisonment in most instances. Fines attached to convictions for health care fraud at the federal level can be up to $250,000 for individuals or $500,000 for corporations, and at the state level, fines can result in triple damages or greater

Possible Defenses Against Health Care Fraud Charges

The most common defenses deployed by attorneys defending health care fraud are similar to those brought up in fraud trials more generally.

First, simple innocence can be a possible defense if the evidence is not particularly convincing, comprehensive or otherwise damning. If there is a degree of doubt as to the strength of the evidence gathered up by the prosecution, a defense team may simply opt to provide their own contrary evidence in the hopes that a judge or jury will see their side as more factually solid.

Secondly, casting shade on the origin of the material evidence gathered by the prosecution can also be a possible defense. If it can be argued that investigators, auditors or other witnesses gathered evidence unlawfully through coercion, threats of force, blackmail or intimidation, that evidence may be considered tainted in a court of law.

Finally, lack of intent or simple “human error” could play a viable part in your case if it can be shown that there is a common error or mistake made that does not play a part in a larger pattern of behavior.

Should I Hire a Health Care Fraud Attorney?

If you are facing charges related to health care fraud, it would be to your benefit to secure the services of a skilled criminal defense attorney. A lawyer experienced in taking on fraud cases, particularly concerning the health care sector, will be able to work with you to craft the best defense possible.

Punishment for committing health care fraud carries significant prison terms and fines. So, if you are accused, or even suspected, of committing health care fraud, it is in your best interests to consult and hire an attorney who is well-versed in federal health care fraud law and state law and experienced in defending health care fraud cases.

What Does a Health Care Fraud Attorney Do?

Your health care fraud attorney will discuss with you the facts and circumstances of the alleged fraudulent act and explain the applicable criminal laws at an initial consultation, which many attorneys provide at no charge.

Several defenses are available to you and your attorney will discuss those with you and recommend the best course of action.

To defend you, your attorney will evaluate the evidence against you to assess its strength and validity and search for gaps, errors and misrepresentations that may have occurred during the investigation. Your attorney also will work to develop mitigating evidence, which is evidence that favors you.

Your attorney will challenge the admissibility of evidence against you, such as evidence illegally obtained, retain expert witnesses to testify on your behalf, and develop evidence proving that the alleged fraudulent act was unintentional, if possible.

  • If a plea bargain is necessary, your attorney, with your consent, will negotiate with the prosecution to reduce the severity of the offense and reduce any prison time and fines.
  • If your case goes to trial, your attorney will aggressively defend you by challenging the government’s witnesses and establishing a ‚Äúreasonable doubt” as to your guilt.
  • If you are convicted, your attorney will bring witnesses to testify about your good character and raise other mitigating factors in an attempt to reduce the severity of the punishment.
  • Finally, your attorney can file an appeal, which means your attorney believes an error in law or court procedure occurred.
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