Healthcare Fraud

What is healthcare fraud?

Fraud - intentionally deceiving and/or cheating.

Healthcare fraud - intentionally deceiving and/or cheating a healthcare program. 

The possible penalties include: time in prison, restitution, and loss of license. The amount of loss directly impacts the amount of time a person may serve in prison. The government can allege a variety of fraud in a variety of ways against a variety of people. Common examples include: 

  • Double billing

  • Phantom billing/Billing for nonexistent services

  • Unbundling/Billing for separate procedures under separate codes instead of “bundling” the billing into one code

  • Upcoding/Overbiling

  • Bogus marketing

  • Kickback schemes/Unlawful Remunerations

  • Identity theft/identity swapping

  • Impersonating a health care professional

  • Forgery

  • Diversion

  • Doctor shopping

  • Selling prescriptions

  • Pill mills

  • Medicare Fraud

  • Medicaid Fraud

There is a lot at stake. The sooner you contact an attorney to help, the greater your chance of a successful result.  

Who can be charged with healthcare fraud?

The charge of Healthcare fraud or any fraud related to healthcare is NOT limited to doctors. The government can charge the owner of a medical group, doctors, medical billers, patients, another company or institution involved with the medical provider or medical group. 

The government holds the doctor or the owner of the practice or medical group, responsible and liable for the actions of its staff. Ex: Doctor A owns “Medical Group” where several doctors work. Dr. B tells the medical biller to upcode several patients’ bills. Dr. A has no idea about this. As the owner of the Medical Group, Dr. A, Dr. B. and the medical biller can all be held liable. 

What should I do if I am being investigated for or accused of healthcare fraud?

First and foremost, DO NOT TALK to anyone. Hire a lawyer immediately. 

  • If you are physically approached let the agent or attorney or investigator know, you have or are hiring an attorney and your attorney will contact them on your behalf. MAKE NO OTHER STATEMENTS.

  • If you receive a letter, you can skip having to tell an agent anything and hire an attorney.

Hiring an attorney creates a wall between you and law enforcement. Once represented they must contact your attorney and not you directly. 

If you receive a letter or a knock, contact us immediately.

Does hiring a lawyer make me look guilty?

Say it with me: NO.

Once the government determines to either send you a letter or knock on your door, time and money has been spent on you. Everything you say will most likely be used against you. 

A criminal defense attorney provides you with a trained professional who can listen to you and speak with law enforcement and the government on your behalf. The government spends little time getting to know - your style, how you convey information, or what you mean when you are speaking. Your attorney’s job is to get to know you as well as your case. 

Ex:  The FBI believes Company A accepted money from Doctor B from a kickback scheme. FBI agents show up to Doctor B’s office (common for the government to show up when and where you are off guard) and start asking Doctor B questions. Doctor B, is busy seeing patients, but wants to cooperate - Doctor B did nothing wrong and has nothing to hide. 

FBI asks Doctor B a question. Because Doctor B is innocent and not thinking too hard about the answer, Doctor B answers a question “Yes.” Truthfully, Doctor B was not 100% certain about the answer, but reasonably believed the answer was Yes. 

This answer can be a crime. IF the government chose to do so, the government could charge Doctor B with False Statements. 

Doctor B committed no fraud, wanted to cooperate, and thought Doctor B was doing the right thing. Doctor B may also be innocent of False Statements, but now there is a Complaint or Indictment against Doctor B - possibly avoidable with an attorney.

Once the government sends the letter or knocks on your door - lawyer up. Immediately.