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Criminal Law - Federal

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What Is Health Care Fraud?

Health care and insurance claims are complicated. With billing codes and confusing charges, it can be easy to make a mistake in your medical insurance claims. However, intentionally misrepresenting your claims or services can be a crime.

If you are charged with making a fraudulent claim, talk to a health care fraud lawyer experienced in defending these types of cases.

What Is Health Care Fraud?

Health care fraud is a broad term that covers many types of illegal and fraudulent behavior related to health care services. Health care fraud is a federal crime that can involve patients, providers, and medical professionals. When any of these parties participate in misrepresentation they can be charged with a federal crime. False representations to receive medical services or benefits are also health care fraud.

What Are Examples of Health Care Fraud?

Some examples of health care fraud by people seeking medical treatment can include:

  • Falsifying eligibility or other medical documents to qualify for Medicaid or Medicare
  • Identity theft, or using someone else’s medical ID card or insurance card
  • Falsifying medical prescriptions or medical records

Medical providers can also commit health care fraud. These cases typically involve health insurance and billing practices. One of the most common ways is when a medical provider shifts an unauthorized cost to the insurance providers. Some of the typical ways medical providers commit health care fraud include:

  • Overcharging for services and upcoding services to get more back from insurance
  • Classifying a medical procedure as more complex than it was
  • Unbundling and charging separately for combined services
  • Invoicing insurance companies for treatment never provided
  • Billing for the same procedure multiple times
  • Mislabeling medical services to get insurance to pay for procedures that normally aren’t covered
  • Waiving a required co-pay for a patient for a general office visit
  • Falsifying a patient’s medical records and diagnosis to justify the need for unnecessary medical treatments
  • Receiving kickbacks for recommending a certain prescription drug or making certain patient referrals

Who Investigates Health Care Fraud?

The FBI and the Department of Justice are the primary agencies responsible for investigating health care fraud. Other agencies that may be involved include the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services. Federal agencies can work with local and state law enforcement to prosecute health care fraud schemes.

What Are the Penalties for Health Care Fraud?

Health care fraud is a federal offense. A conviction can result in the following penalties:

  • Up to 10 years of prison for a first violation
  • Up to 20 years if the violation results in a serious bodily injury
  • Life in prison if the fraud resulted in death
  • Fines, civil penalties, and restitution for the amount defrauded

You can also face criminal prosecution for health care fraud under state laws.

There are other federal laws that make it a federal crime to commit health care fraud. Fraud can also commonly be prosecuted under the federal False Claims Act. Criminal penalties include:

  • Up to five years in prison
  • Restitution for the amount of unauthorized payment
  • Fines of up to $250,000 for individuals and $500,000 for businesses
  • Civil fines and penalties

Other statutes that federal prosecutors may use to prosecute you for health care fraud include the Anti-Kickback Statute, where you can face up to five years in prison. Make sure you check your explanation of benefits to ensure that it correctly reflects the medical treatment and the appropriate reimbursement.

How Can a Lawyer Help With Health Care Fraud Investigations?

Don’t wait until it is too late and you are already charged. If you believe you are being investigated for health insurance fraud, get legal advice from an experienced health care fraud attorney as soon as possible. Your lawyer can deal with the government on your behalf to protect your rights.

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