Health Care Fraud

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Rise in Federal Investigations of Medical Billing and Filing of Federal Health Care Fraud Charges

Health Care Fraud (Medicare Fraud, Medicaid Fraud) has been a growing concern of the federal government for several years now, and it is expected that federal investigation and prosecution of health care fraud and health insurance fraud will increase in the upcoming decade, especially as facets of Obamacare become effective.

In October 2012, for example, U.S. Attorney General Eric Holder and Secretary of the Department of Health and Human Services Kathleen Sebelius announced health care fraud charges filed against 91 people (doctors, nurses, and other licensed professionals) as a result of an investigation crossing 7 different cities by their “Medicare Fraud Strike Force.” The nationwide federal investigation into health care billing practices by medical caregivers across the country is expected to continue.

What is Health Care Fraud (Medicare Fraud, Medicaid Fraud)?

Health Care Fraud, including Medicare Fraud and Medicaid Fraud, involves deceptive practices in the healthcare industry related to insurance claims. A charge of health care fraud is simply an allegation that there has been deception where insurance claims are made for services or equipment with commercial insurance carriers as well as Medicare or Medicaid. The health care fraud charge is that the service or equipment listed on the claim was never provided to the patient or that the patient did get something – but was told it was being provided to them at no charge. Below are examples of previous felony charge allegations:

• Fraud in charges for services not given;
• Fraud in charges for equipment not provided and/or
• Fraud in providing and billing for things given or provided that the government now alleges were unnecessary.

Free equipment (wheelchairs, scooters, etc.), for example, in health care fraud cases, is offered by the manufacturer to an individual. Then, the insurance company receives a claim for the equipment – equipment that the government will argue was not needed or was never received.

Another common allegation of health care fraud is exaggerated insurance claims filed by health care providers. Here, physicians, therapists, testing labs, clinics, hospitals, and any other kind of medical provider complete and file insurance claims for the convenience of the patient, and later, the government charges that these claims are either padded or phony.

What about the physician’s review of the claim? While doctors must sign certificates that claims are authentic, health care fraud charges assert that the physician was deceptive and signed fake claims for profit or someone working in claims processing forged the necessary doctor’s signature on the claim certificate.

Medicare Fraud | Medicaid Fraud | Health Care Fraud – Defense against Government Fraud Charges

Texas Board Certified Criminal Defense attorney Michael Lowe represents clients throughout the State of Texas who face federal or state health care fraud charges. Providers that can face investigations or charges of Medicare Fraud, Medicaid Fraud, or other forms of Health Care Fraud include:

• Physicians / Doctors
• Nurses
• Therapists
• Personal Care / Home Health Care Attendants
• Clinics
• Labs
• Hospitals
• Nursing Homes
• Long-term Term Care Facilities
• Equipment Providers
• Home Health Care Companies
• Medical Billing Claims Services Companies

Even Mere Suggestions of Health Care Fraud or Abuse Can Have Serious Consequences

For those medical professionals and health care companies that are under investigation, suspect that they may be investigated, or face charges that have been filed in state or federal court, not only is there the danger of criminal sentencing with incarceration and fines, but there is the reality that these kinds of things, even rumors of being investigated for fraud, can cause serious harm to professional reputations and the future success of medical practices and company growth.

Years of dedicated service can be endangered even if no formal fraud charges are ever filed in court.

| Have a Question? Call Michael Lowe for a Free Initial Consultation. |

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Common Allegations in Medicare and Medicaid Fraud Cases

When targeting health care providers suspected of improperly billing Medicare and Medicaid, federal authorities can pursue charges for a wide range of statutory and regulatory violations. All of these charges are serious, and this makes it critical to have an experienced Dallas federal health care fraud defense lawyer on your side.

Some examples of common allegations in Medicare and Medicaid fraud cases include:

• Certification and Licensing Issues – Health care providers and other entities that bill Medicare and Medicaid must certify compliance with the applicable billing rules and regulations. Health care providers must also ensure that all relevant services are provided only by licensed and properly credentialed individuals. Certification and licensing issues can lead to recoupment demands, fines, and other penalties.
• False Billing – False billing, also referred to as “phantom billing,” involves billing Medicare or Medicaid for services not rendered or items not provided to patients. Physicians, therapists, hospitals, clinics, testing labs, and other health care providers and facilities can all face phantom billing allegations for both intentional billing fraud and inadvertent mistakes.
• Lack of Medical Necessity – To qualify for reimbursement through Medicare or Medicaid, health care services and items must be deemed “medically necessary” under the applicable program rules. If you are facing allegations of billing Medicare or Medicaid for services or items that lacked medical necessity, Texas federal health care fraud defense lawyer Michael Lowe can help protect you by all means available.
• Overbilling – Health care providers in Texas regularly face scrutiny for overbilling Medicare and Medicaid. This includes “upcoding,” which involves using a higher billing code than the one that applies to the health care services or items provided, as well as “unbundling,” which involves billing separately for related services or items at their individual, non-discounted rates.
• Unlawful Referral Fees and Other “Kickbacks” – The Anti-Kickback Statute and Stark Law prohibit physicians, hospitals, and other health care providers and entities from engaging in various types of financial relationships and transactions. Parties on both sides of unlawful referral fees and other “kickbacks” can face serious penalties under these laws.

Again, these are just examples. Allegations of Medicare and Medicaid fraud can take many other forms as well—and, if you are facing scrutiny from federal authorities, it is imperative that you have a comprehensive understanding of the allegations (and potential allegations) at hand. Texas federal health care fraud defense lawyer Michael Lowe can help you understand the risks you are facing, and he can help you execute a targeted defense strategy focused on avoiding unnecessary consequences.

Federal Laws and Regulations that Apply to Health Care

Health care is among the most heavily regulated industries in the United States. Providers and other entities that bill Medicare and Medicaid must comply with numerous laws and regulations, and any violations can present risks for enforcement. Some of the key federal laws that apply in Medicare and Medicaid fraud cases include:

Anti-Kickback Statute

The Anti-Kickback Statute prohibits health care providers and other entities in Texas from offering, paying, soliciting, or receiving compensation for the referral of Medicare or Medicaid patients. It prohibits “kickbacks” in various other scenarios as well. While exceptions, or “safe harbors,” apply in some cases, violations are common, and they can present risks for civil or criminal penalties depending on the specific allegations involved.

False Claims Act

The False Claims Act prohibits entities and individuals from submitting any “false or fraudulent claim for payment” to the federal government. This includes submitting invalid claims for Medicare or Medicaid reimbursement. Similar to the Anti-Kickback Statute, the False Claims Act includes provisions for both civil and criminal enforcement.

Health Care Fraud Statute

The federal health care fraud statute is a criminal law that makes it a federal offense to “knowingly and willfully” defraud (or attempt to defraud) Medicare or Medicaid. Federal prosecutors can pursue charges under the health care fraud statute in addition to pursuing charges under the Anti-Kickback Statute, the False Claims Act, and other pertinent federal laws.

Medicare and Medicaid Billing Rules

From coding compliance to adequately documenting medical necessity, there are numerous aspects to managing compliance with the Medicare and Medicaid billing rules. Noncompliance can create exposure to liability for recoupments and other monetary penalties, and, in severe cases, it can lead to Medicare or Medicaid exclusion.

Stark Law

The Stark Law prohibits “physician self-referrals.” This term has a broad—and complex—definition, and physicians (and others) will often find themselves facing Stark Law scrutiny unexpectedly. Dallas federal health care fraud defense lawyer Michael Lowe has extensive experience representing clients in Stark Law matters.

Texas Health Care Fraud Lawyer

As a former prosecutor turned criminal defense lawyer with over 150 jury trials defending clients against charges brought by district attorneys and U.S. federal prosecutors in Dallas County, Tarrant County, and elsewhere in the State of Texas, Board Certified Criminal Lawyer Michael Lowe not only brings his years of experience to each case, he also dedicates 100% of his law practice to the defense of those being accused of a crime under Texas or federal law.

With a streamlined law firm that coordinates its efforts to give each client the personal attention that they need and deserve when fighting against the government and the possibility of jail time, fines, permanent marks on public records, prison incarceration, loss of licensure, loss of jobs, absence from family events and everyday living, Michael Lowe maintains an efficient and excellent criminal trial practice that is ready to help you or your loved ones in your defense against criminal charges from pre-arrest investigation to post-trial appeals.

Contact A Texas Health Care Fraud Lawyer Today

Are you facing a threat of federal health care fraud investigations? Don’t risk your reputation; contact Michael Lowe, a Texas Board Certified Criminal Defense attorney with extensive experience in defending against health care fraud charges. To discuss your case in a free and completely confidential consultation, please contact Dallas Board Certified Criminal Lawyer Michael Lowe today.

FAQs: Health Care Fraud Defense

What Are the Penalties for Improperly Billing Medicare or Medicaid?

The penalties for improperly billing Medicare or Medicaid depend on the nature of the scrutiny you are facing. Medicare and Medicaid auditors have the authority to impose recoupment liability and deny pending claims, and they also have the ability to institute pre-payment review in appropriate cases. In federal health care fraud investigations, providers and others can face either civil or criminal penalties depending on the allegations involved. Civil penalties can include fines and program exclusion, while criminal health care fraud charges also present the risk for prison time.

Do I Need a Health Care Fraud Defense Lawyer for a Medicare or Medicaid Audit?

Medicare and Medicaid audits can present significant financial risks, so we strongly recommend engaging a Texas federal health care fraud defense lawyer to represent you as early in the audit process as possible. Importantly, not only can Medicare and Medicaid auditors impose certain penalties directly, but they can also refer cases to the federal government for civil or criminal prosecution when warranted.

What Should I Do if I Am Under Investigation for Federal Health Care Fraud?

If you are under investigation for federal health care fraud, you need to be extremely careful. In this scenario, mistakes can prove very costly, so you need to be sure that you are making informed decisions throughout the process. Dallas federal health care fraud defense lawyer Michael Low can explain everything you need to know and communicate with federal authorities on your behalf.