Health Care FraudThe United States Congress—through the Health Insurance Portability and Accountability Act of 1996 (HIPAA)—specifically established health care fraud as a federal criminal offense under United States Code, Title 18, Section 1347, with the basic crime carrying a federal prison term of up to 10 years in addition to significant financial penalties. This statute also provides that should a perpetrator's fraud result in the injury of a patient, the prison term can double, to 20 years; and should it result in a patient's death, a perpetrator can be sentenced to life in federal prison. Congress also mandated the establishment of a nationwide "Coordinated Fraud and Abuse Control Program," to coordinate federal, state and local law enforcement efforts against health care fraud and to include "the coordination and sharing of data" with private health insurers. Many states also have responded vigorously since the early 1990s, not only by strengthening their insurance fraud laws and penalties, but also by requiring health insurers to meet certain standards of fraud detection, investigation and referral as a condition of maintaining their insurance or HMO licenses. The Law Offices of Roderick C. White aggressively represents private individuals, doctors/physicians, medical clinics, hospitals, durable medical equipment providers (DME providers) and other health care companies throughout the United States that are facing potential and/or actual allegations of all health care fraud allegations. Depending on the circumstances, there are numerous defensive strategies that can be employed to successfully defend against health care fraud allegations. If you or a loved one are being investigated for health care fraud or have already been formally charged, the Law Offices of Roderick C. White will gladly meet with you to discuss the aggressive defensive strategies available. Below are links to a more detailed discussion of some common federal health care fraud allegations: • Medicare / Medicaid Fraud One of the more common allegations that heath care fraud defense attorneys must deal with is Medicare fraud/Medicaid fraud. The federal government is vigilant in trying to catch institutions for various forms of health care fraud, Medicare fraud or Medicaid fraud, including: • Trying to bill for services not rendered Billing For Goods/Services Not Actually Provided A common type of healthcare fraud scheme is billing for a treatment or procedure never rendered -- such as X-rays, laboratory tests, drugs never dispensed. Paying "Kickbacks" In Exchange For Referring Business "Kickbacks" are common in healthcare fraud cases. Federal law generally prohibits payments to individuals who refer patients to a particular hospital or doctor. Medicaid fraud prosecutions have been brought, for example, against doctors for splitting fees in return for rent, demanding cash payments from Medicaid patients, and taking money in exchange for patient referrals. Billing for Medically Unnecessary Tests Many federal prosecutions allege that health care providers misrepresent the diagnosis and symptoms on patient records and then submit invoices to insurance companies to receive a higher rate of reimbursement. An example of this would be a patient who allegedly visited the doctor for a common cold treatment, but the insurance company was billed for a condition diagnosed as pneumonia, with associated pneumonia testing. Success in these types of allegations typically hinge upon consistent and/or irregular documentation. Charging Personal Expenses To Medicaid This allegation is often faced by nursing homes and their administrators. Nursing homes are reimbursed based upon the annual submission of a cost report. The inclusion of personal expenses in these costs reports is fraudulent. An example of this occurs when a nursing home administrator includes the cost of his personal car or home on the cost report. Inflating the Bills For Services Provided This regularly occurs in the Medicaid transportation sector when van/taxi companies are accused of greatly inflating their claimed mileage in order to receive greater reimbursement. Managed Care Organizations (MCOs) Managed care presents different fraud issues. Whereas in standard healthcare reimbursement situations, the fraud is characterized by over-billing, a managed care environment creates an incentive to deny care to patients/consumers. This means that while a fee has been paid by the MCO to the doctor for covered services, the services are allegedly denied or cut back for other than sound medical reasons. Fraud in MCOs also arises in enrollment practices whereby healthy patients are "recruited" to join certain MCOs in a practice known as "cherry picking." Often, they are paid in some fashion for their enrollment. Double billing occurs when the provider obtains payment from two sources. For example, a provider involved in a drug study bills the insurance company while at the same time receiving payment from the pharmaceutical company. Similarly, two insurers or public programs, or both, may be billed for the same service. Some health care fraud allegations are allegedly committed by patients/consumers. Some examples of common consumer deception fraud allegations include the following: • using someone else’s insurance card for benefits |
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