Healthcare Claims Fraud
Healthcare claims fraud is a type of insurance fraud, and is typically viewed as a "white collar crime". In part because of ever-rising healthcare costs, both state and federal authorities aggressively investigate and prosecute efforts to defraud private insurance carriers and government agencies by means of false claims for health-related services and products.
In its most general sense, healthcare claims fraud involves intentionally filing false or fraudulent claims for health or medical products or services for the purpose of obtaining payments that the filer is not entitled to receive. As a result of increasing efforts to prosecute these cases, things that were once viewed as minor billing errors are now frequently prosecuted as attempts to fraudulently obtain payment from an insurance company or government agency.What are some types of conduct that can be considered fraudulent?
Healthcare fraud takes a variety of forms including, but not limited to:
- Billing for services not provided;
- Submitting fake bills;
- Duplicate billing;
- Failing to accurately disclose on a bill or related documents the dates services were provided, the nature of the services actually rendered, or the identities of members or providers;
- Billing non-covered services as covered services;
- Altering medical records;
- Intentionally altering a diagnosis or procedure to increase or maximize payment;
- Prescribing unnecessary tests, treatment or services;
- Misrepresenting a provider's credentials or licensing status;
- Receiving kickbacks in return for patient referrals;
- Billing for services provided by unlicensed or untrained personnel;
- Failing to supervise unlicensed personnel;
- Distributing or providing unapproved drugs or devices;
- Waiving co-payments;
- Medical equipment fraud;
- Transportation/ambulance services fraud;
- Intentionally stating false information on an application for programs or services;
- Using someone else's Medicare card to obtain coverage;
- Seeking payment of claims for services, treatment or medication that was not received;
- Forging or altering applications, claim forms or other documents;
- Intentionally enrolling ineligible employees for healthcare coverage;
- Falsifying hiring or termination dates to expand coverage periods; or
- Misrepresentation of an employer group to obtain coverage.
The fines and penalties for healthcare claims fraud can include jail time, as well as substantial civil and criminal monetary penalties. Defendants found guilty of these offenses can, under certain circumstances, be required to reimburse the defrauded victim of whatever monies were paid out.What are some of the special concerns for licensed professionals charged with healthcare fraud?
Healthcare claims fraud presents special issues for licensed professionals, including doctors, dentists, physical therapists, psychologists, social workers or other mental health professionals, nurses and eye care providers. In addition to the penalties usually imposed in healthcare claims fraud cases, these professionals can face the suspension or revocation of their license. Thus, a licensed professional may not only be required to appear in court in connection with a criminal case, but can also face disciplinary proceedings before their licensing authority.Is the defendant or subject of the investigation always an individual?
Defendants or subjects in these cases are not always individuals. Institutions such as hospitals, clinics, outpatient surgical centers, nursing homes and durable medical equipment retailers can also be charged with healthcare claims fraud.What should I do if I am being investigated or charged?
If you or your institution are being investigated for healthcare claims fraud, the best course of action is to seek legal representation immediately upon learning of the probe. If possible, don't wait for charges to be filed. If, however, you or your institution have been charged with healthcare claims fraud, the best course of action is to seek aggressive representation from an experienced criminal defense attorney.
Criminal defense attorney James S. Friedman, Esq., has considerable experience defending healthcare claims fraud cases in both state and federal court. If you have been charged with healthcare fraud, or you or your institution or business is being investigated, DO NOT ATTEMPT TO DISCUSS OR EXPLAIN THE SITUATION WITH THE INSURANCE CARRIER, GOVERNMENT AGENCY OR INVESTIGATOR. Instead, contact Mr. Friedman immediately to start planning an aggressive defense.