Health care fraud is a crime where a consumer or dishonest provider submits false or misleading information on a claim to gain a benefit or profit. Most cases are described as Medicare and Medicaid abuse, and will get classified as federal felonies.
Different groups within the healthcare system – patients, providers, insurers – may commit this crime. Charges may also stem from insurance fraud if the act is committed against a private insurance carrier.
Charges of Healthcare Fraud and Insurance Fraud
Estimates show that approximately 10% of all the money spent on health care goes toward fraudulent claims. There are a variety of charges of healthcare fraud and insurance fraud that could threaten your medical career.
Although anyone working in the healthcare field can commit fraud, it is most commonly perpetrated by providers who want to get more money from insurers. Some of the common practices that lead to charges include:
• Overbilling for services
• Double billing or filing duplicate claims for one procedure or service
• Inflating the cost of medical procedures
• Performing procedures that were not necessary
• Falsifying patient records
• Providing referral kickbacks
Patients who commit fraud are usually charged with pretending to have a medical condition so they can receive prescription medications to sell. Some patients may also use someone else’s insurance information to receive medical treatment. Others will simply falsify medical claim information to defraud the insurance company.
Distinguishing between Fraud and a Mistake
It is important to make the distinction between fraudulent acts and mistakes, improper payments or omissions. For an entity or individual to commit fraud, there must be a plan to knowingly engage in actions with the intent to receive some financial gain from the outcome.
For instance, fraud is not mistakenly billing a patient for treatment she or he never received. In contrast, a healthcare provider may knowingly perform procedures or treatments that the patient does not need. When the provider bills the insurer for those same procedures or treatments to make a profit, the provider has committed fraud.
There are instances when two providers work in concert to defraud the insurance company. Other times, the patient and health care provider may work together to commit fraud. This could be considered conspiracy to commit insurance fraud or health care fraud. Doing this is not a mistake, but rather, an attempt to file false claims for monetary gain.
Healthcare and Insurance Fraud Carry Serious Penalties
Penalties for federal health care fraud can be criminal and/or civil, and carry fines, imprisonment, an order to pay restitution, and probation.
• Criminal – both federal and state level health care fraud charges can result in long-term serious consequences if the defendant is convicted.
• Civil – usually pursued by private insurers in state court. Criminal penalties are not involved and often result in a court order for the defendant to pay fines and restitution. Some cases may lead to punitive damages that exceed actual damages.
• Fines – false Medicare or medicaid statement by individuals can be up to 0,000 in fines per offense. Organizations face fines up to $500,000 per fraud offense. Conspiring with another entity to make false claims results in multiple counts of fraud with millions or billions in fines.
• Prison sentence – when a false claim or false statement is made regarding Medicare and Medicaid, the individual faces a 10-year sentence, per offense, in a federal prison. If serious bodily harm or death occurred as a result of the health care fraud, the prison sentence could rise to 20 years.
• Restitution – a judge can order the defendant(s) to pay back all the money that was illicitly obtained through health care or insurance fraud. This can occur in federal or state courts.
• Probation – a health care fraud conviction may lead to probation or a reduced sentence and parole. Both programs will limit the person’s freedom. A person may spend several months or years fulfilling probationary terms. After spending at least one-third of the sentence, the person might be eligible for parole. Probation or parole come with specific conditions that, if not fulfilled, can lead to a revocation and a return to being incarcerated.
An Aggressive Healthcare and Insurance Fraud Lawyer Makes a Difference
Being charged with health care or insurance fraud can be just as upending to a person’s life as a conviction. If this is what you are facing, contact our office today. One of the aggressive lawyers at Spodek Law Group, PC will discuss the specifics of your case and find the best options that will protect your rights.
Home Healthcare Services Fraud Lawyers
Many people rely on home healthcare services. It could be people who have had surgery and are trying to recover, people who have an illness and can’t perform the daily activities without assistance or elderly individuals who don’t want to go to a nursing home but need assistance with things like bathing, changing clothes or even cooking. Unfortunately, there are ways to commit home healthcare fraud. If you are charged with doing something like this, it’s important to contact an attorney as you could face criminal charges by the company that you work for as well as a civil suit by the person’s family.
When home healthcare providers commit fraud, they are violating the False Claims Act. Workers often have to bill government programs in order to get compensation for the services that are provided. An example would be to bill Medicare for providing services for an elderly individual who needs help with breathing treatments. The person might claim that the services that are provided costs more than what they really are, which would mean that the worker and the company would end up getting more money.
Another way that home healthcare workers commit fraud is by doctoring paperwork and claiming that someone who is not eligible for healthcare services is eligible. This is often easy to do as all the worker has to say is that the person needs the assistance of someone else. The paperwork can state that the person can no longer provide proper care and that the family requests that someone be in the home. However, the client might not really need those services and can provide care alone, resulting in money being paid to the healthcare company in a false manner. A qualification for receiving home healthcare through Medicare is that the person must be home-bound. This means that the person is unable to get out of the home without assistance. It also means that the person can’t do the basic tasks every day without some kind of help. It doesn’t mean that every task can’t be completed but that the majority requires some type of help, such as getting in and out of the shower or cleaning the home.
Home healthcare agencies can bill for medical procedures that aren’t needed. The worker might request that a service needs to be provided for the client without receiving the treatment and instead keeping the money that is set aside. Each treatment that is given requires a code to be entered on paperwork that is turned in for billing. Some codes are similar, but one might result in getting more money for the company. This is a way that many workers commit fraud as the only thing that needs to be done is to enter a different code on the paperwork. If you pay for or receive kickbacks for any kind of referrals from the patient or the family, then you’re in violation of the Federal Anti-Kickback Statute. This is a way for the company as well as the worker to make money since a bonus is likely given to workers who increase the caseload for the business.
Another way that home healthcare workers often commit fraud is by entering into improper financial relationships with others who provide healthcare. This could be a doctor or a nurse who provides care for the client. The worker would talk with the provider to come up with a way to get more money from the client or the insurance company that is paying for the services. The extra money would be divided between the provider and the worker so that both get more money. An attorney can look at ways to get charges that are brought for healthcare fraud reduced. Most of the time, this is a crime that results in heavy fines, a jail sentence or probation.
Insurance Fraud: Definition And Common Forms
According to the FBI, insurance fraud costs U.S. citizens over $40 billion in increased premiums every year, and this amount does not account for medical insurance. The sum is huge, and taking this into consideration, the federal and state law enforcement authorities take action in order to combat related crimes. Let’s dive into the topic. Our insurance fraud attorneys will explain what common types of fraud are and why people commit it, what consequences it might have and what penalties an accusee might face if found guilty of the crime.
Basically, it is an act of illegally exploiting an insurance contract either by the insurer or by the policyholder.
Some commons types of fraud committed by insurers include:
Premium diversion. It is the most common type, and it is constituted by the failure to pass a premium to the company or selling policies without authorization and later failing to pay claims.
Fee churning is set of reinsurance agreements transactions aimed at making an insurer going bankrupt by wasting premiums on commission payments.
Asset diversion is buying an insurance company’s shares with borrowed funds and later paying off the debt with the company’s assets.
Workers’ compensation fraud is selling policies illegally, sometimes at a lower cost, and later failing to pay claims.
Case Study
We represented an appraiser who was charged with manipulating the value of the damage done to an automobile in a car accident in order to reduce the amount of payment. Our insurance attorneys managed to convince the prosecutors that the miscalculation was fully unintentional, thus reducing the sentence down to a $1,000 fine and no prison time.
Common examples of insurance scams committed by policyholders are the following:
falsification of data at the time of applying for insurance;
exaggeration of claims in order to receive a larger claim;
staging events, for example, car accidents or vehicle theft, and faking injuries in order to obtain a claim;
arson of one’s own house or other property with the purpose of obtaining profit.
Case example from our own practice
Our firm defended a client charged with setting on fire his own cafe with the purpose of receiving a compensation. We were able to convince the prosecutors that the property owner did think that this was an accident, making his claim fully legitimate, though later during the prosecution process it was discovered that a frustrated employee committed the arson.
Why do people commit insurance fraud?
According to the FBI, the U.S. insurance industry is a highly profitable business – the amount of premiums collected by providers totals $1 trillion per year. Such a big sum makes it very alluring for some individuals to seize a piece of the pie – illegally. Some people don’t see anything criminal in trying to inflate the value of the damages inflicted in the course of an insured event. Others deliberately and in full knowledge of the possible consequences of their doings elaborate cunning plans to defraud either providers or beneficiaries.
Whatever the motive and the nature of the crime, each specific fraudulent activity ultimately takes money from payers of premiums. And therefore the government actively prosecutes such crimes and applies severe penalties to the indicted in order to discourage others from committing them.
Consequences and penalties
The penalties vary greatly depending on the severity of a crime. It might be a $500 fine for a $50 false claim, and as you see, in this case the amount of a fine applied exceeds the averted damage almost 10 times.
Falsification of data on an insurance application is also a serious crime that may lead to up to 2 years of prison time and/or a fine of up to $10,000.
For other cases, where the crime is defined as a Class C felony, for example, depending on the value of the damage and the legislature of a specific state the sentence may include up to ninety-nine years of imprisonment and a fine of no more than $10,000, as well as full restitution.
As you see, the consequences of committing an insurance-related crime can be extremely harsh and therefore each individual case requires expert help of an insurance fraud lawyer.