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 $250,000 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 Raiser & Kenniff, PC will discuss the specifics of your case and find the best options that will protect your rights.
Todd is a miracle worker who will work tirelessly for you and your family. He is one of the few attorneys i've met - who I earnestly trust to protect me, and who I am happy to refer to our friends and fellow family members. The Spodek Law Group is someone you want on your side, because they will treat you just like family. Todd and his team are available 24/7, and they always answered our calls. Even when we were being irrational, and crazy - they were calm and super helpful. Just call Todd. He gives you a free consultation and is very understanding.- Donna & Robert
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