The healthcare fraud defense attorneys from Westfall Sellers have created a healthcare fraud defense guide for you to feel more prepared during your healthcare fraud case. We’ll be discussing what is healthcare fraud, why providers tend to be charged with fraud, and what an attorney can do for you and your case.
If you have been accused of committing healthcare fraud or violating the Anti-Kickback Statute, consider working with one of Westfall Sellers’s healthcare fraud attorneys who understands the complexities of your industry and the unique needs of your case.
What is healthcare fraud?
The National Health Care Anti-Fraud Association estimates that approximately $68-$230 billion dollars a year are made as a result of fraudulent healthcare spending. Though healthcare fraud cases are deemed white collar crimes –– crimes committed on a typically large scale –– any individual can be charged with healthcare fraud.
A healthcare fraud offense is classified in the Texas Penal Code Chapter 35A as when a person knowingly makes a false statement or misrepresentation that a person received payment or benefits under an unauthorized health care program, the benefit or service was not medically necessary, and/or was charged for more than the service or benefit was worth.
Common examples of healthcare fraud include:
- Billing for a non-covered service
- Filing duplicate claims for one service rendered
- Altering dates and identities related to rendered services
- Modifying medical records
- Prescribing unnecessary treatment, drugs, and/or procedures
- Falsifying diagnoses for higher payments
Benefit programs such as medicare audit providers to review their patient records for false statements, unnecessary treatments, or anything else that could result in undue reimbursement from the payer. These audits ensure that their programs are being used appropriately. In some cases, however, mistakes are made, whether the party knows it or not. In other cases, whistleblowers report healthcare fraud cases directly to these organizations.
What are the penalties for healthcare fraud?
Healthcare charges in Texas range from misdemeanors to felonies depending on how much money was involved in the crime. For example, claims under $50 will be classified as a Class C misdemeanor; however, healthcare fraud claims over $1,500 mean state felony charges (meaning potential decades to life in federal prison). Currently, False Claims Act penalties can run for $20,000+ per violation.
Penalties for healthcare fraud expand beyond jail time and fines. Frankly, being convicted of (or even accepting a plea bargain) for federal healthcare fraud can have severe repercussions on your career. Namely, you may face the following:
- Loss of your medical license
- Loss of DEA registration
- Exclusion of your practice from Medicare and Medicaid
- Seizure of assets (and potential loss of these assets via criminal forfeiture)
- Inclusion of negative information the National Practitioner Data Bank (NPDB)
- Restitution (in addition to fines)
Because the penalties can be severe, having federal fraud defense lawyers in your corner is extremely important. The right attorney can help you build a strong case to defend you and your practice against allegations of healthcare fraud.
What are some common health care fraud defenses?
The type of defense you and your healthcare defense lawyer pursue will be highly dependent on the specifics of your case. That said, there are several common types of healthcare defenses. These include:
- Lack of intent: Notice how the definition of healthcare fraud says that the provider “knowingly” commits fraud. Sometimes fraud can be committed without the party even knowing it has occurred.
- Compliance programs: If you have instituted a comprehensive compliance program (a program put in place specifically to deter healthcare fraud) the fact that you have taken the time to implement such a program can be used to argue for lack of intent.
- Consent: A victim accuses you of fraud, but you have documentation that the person accusing you consented to the medical steps you took.
- Voluntary disclosure: Maybe you knowingly committed fraud and want to get ahead of charges by reporting yourself. The agencies that oversee federal fraud do incentivize self-reporting with a potential reduction in fines, but, frankly self-reporting still incurs risks. It is not recommended to self-report without legal representation.
- Insufficient evidence: Whether you intended to commit healthcare fraud, there needs to be enough evidence to prove your intent beyond a reasonable doubt. If there’s not enough evidence, then there’s no case against you.
Your lawyer may also argue that your alleged healthcare fraud infraction was covered under Stark Law Exceptions or within Anti-Kickback Statute Safe Harbors. Regardless, government investigators are usually quick to jump on any type of healthcare fraud case, regardless of whether or not you’re guilty. That’s why it’s important to work with a healthcare defense lawyer as soon as possible to start building a strong defense from the start.
Should you hire a lawyer for healthcare fraud defense?
Yes, and soon. The reality is, U.S. healthcare law is quite complex and carries heavy penalties for those who violate it. It can be a scary situation to be in. It takes an experienced healthcare fraud defense attorney with specialized knowledge of healthcare statutes, provider guidelines, and more to handle these types of cases.
Proper negotiations done early on by your lawyer can help prevent unnecessary trials and charges. If that is not an option, your attorney will spend time collecting well-documented evidence and analyzing the state of your healthcare fraud case to give you an honest assessment of your chances in court.
It is an attorney’s job to help you navigate the ins and outs of the intense healthcare legal process while taking the best courses of action to refute the claims and manage your practice’s reputation.
If you believe you have been accused of false or fraudulent healthcare allegations, or believe you are under government investigations, contact the attorneys at Westfall Sellers immediately.
Need healthcare fraud defense? Call the fraud defense attorneys at Westfall Sellers today!
The healthcare fraud attorneys at Westfall Sellers represent organizations under criminal investigation at the state and federal levels. In healthcare fraud cases, it’s important to have an attorney that can gather sufficient evidence to refute these claims –– after all, the reputation of your practice depends on it.
You only get one shot at this. Trust the legal team at Westfall Sellers to fight for your rights. Contact our team online today or call 817-345-7920.
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