Healthcare fraud can be committed by doctors, nurses, pharmacists, medical office administrative staff and billing companies, laboratory owners, marketers, insurance brokers, patients, and others accused of intentionally deceiving the healthcare system to receive unlawful benefits or payments. The FBI is the primary agency for investigating health care fraud for federal and private insurance programs, often working in conjunction with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).
Federal healthcare fraud typically involves deceptive practices that result in unauthorized benefits from health insurance providers, especially those funded by the federal government, such as Medicare and Medicaid. The crime includes overbilling, billing for services not rendered, misrepresenting services provided, and falsifying a patient’s diagnosis to justify tests, surgeries, or other procedures that aren’t medically necessary.
The fraud and abuse laws under the False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law (Stark Law) often interact in a healthcare fraud case and can significantly influence your potential for prosecution and severe criminal exposure. While “Healthcare Fraud” comes in many different forms and can implicate several different federal statutes, the primary statute for federal healthcare fraud is 18 U.S.C. § 1347. This law makes it illegal to knowingly and willfully execute, or attempt to execute, a scheme or artifice:
To obtain a conviction for healthcare fraud, the government must prove several elements beyond, and to the exclusion of, any and all reasonable doubt. These elements include:
The healthcare fraud attorneys at the Rossen Law Firm regularly defend against a variety of types of fraud, as the crime can come in various forms, but common allegations include:
The penalties for healthcare fraud are severe. They can include substantial fines, restitution, asset forfeiture, and imprisonment. For example, under the Federal Health Care Fraud statute (18 U.S.C. § 1347), the potential penalties include fines and up to 10 years in prison or up to 20 years if the fraud results in serious bodily injury.
Even worse, the federal government will almost always charge an individual with related offenses that carry severe penalties, including Wire Fraud, Money Laundering, and Conspiracy (by itself or as a conspiracy to commit wire fraud or conspiracy to money laundering, which carries increased penalties).
On top of the penalties that one could face, such as prolonged incarceration and hefty fines, healthcare fraud convictions can bring extremely harmful collateral consequences, affecting our clients and their loved ones far after the criminal penalties are over. Just a few of the severe collateral consequences include:
The Federal Sentencing Guidelines set out a uniform sentencing policy for individuals and organizations convicted of felonies and serious (Class A) misdemeanors in the United States federal courts system. In healthcare fraud cases, the Sentencing Guidelines consider the nature of the crime and the offender’s criminal history to determine the recommended sentence.
Each of these factors will be calculated to determine the final offense level, which is then used with the defendant’s criminal history to determine the sentencing range in months. The Guidelines are advisory, not mandatory, meaning the judge has the discretion to sentence the defendant above or below the recommended range under certain circumstances. However, judges must consider the Guidelines in all cases and provide written reasons for departures from the recommended range.
These are just the primary factors that apply, and in the context of healthcare fraud, several other potential factors within the sentencing guidelines may apply to your case. Given the complexity of sentencing in healthcare fraud cases, it’s essential to have the experienced legal counsel of the Rossen Law Firm to navigate these issues.
The Anti-Kickback Statute (AKS) is a federal law that prohibits the exchange (or offer to exchange) of any type of gift, bribe, kickback, or rebate for referrals for services paid for by federal healthcare programs such as Medicare and Medicaid. This law is outlined in 42 U.S.C. § 1320a-7b.
The conspiracy to violate the federal Anti-Kickback Statute is punishable by a maximum potential penalty of five years in prison and a fine of $250,000, or twice the gross profit or loss caused by the offense, whichever is greater.
Additionally, violations of the Anti-Kickback Statute are considered felonies. The penalties can be severe and include:
Under the AKS, it is a criminal offense to knowingly and willfully solicit, receive, offer, or pay any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or kind, in return for:
The AKS is an “intent-based” law, meaning that a person must have a deliberate intent to induce or reward referrals for services paid for by a federal healthcare program.
It is imperative to note that certain “safe harbors” – practices that are protected even if they may technically violate the AKS – typically include certain types of investment interests, rental agreements, and personal service arrangements. However, the specific requirements for each safe harbor must be strictly met to avoid potential liability. It’s essential to consult with an attorney well-versed in healthcare law when navigating these complex issues related to safe harbors and violations of the AKS.
Defending against a federal healthcare fraud charge requires a deep understanding of the healthcare system, laws, and a well-thought-out strategy. Here are just a few of the common defenses utilized by the healthcare fraud defense attorneys at the Rossen Law Firm:
Successful defense of a Medicare case will often require a sophisticated understanding of the reimbursement principles involved in that case. The reimbursement principles under Medicare have grown increasingly complicated over the years. Different entities are paid under different methodologies (e.g., cost-based, charge-based, or fee schedules) and may be subject to limits based on several factors. Some providers are paid directly, and some are paid by the patient and reimbursed by Medicare. Hiring an attorney who understands the complexities of Medicare reimbursement is crucial.
Given the unique complexity of healthcare fraud cases, it’s essential to have a lawyer with experience in healthcare fraud defense. The healthcare fraud defense attorneys at the Rossen Law Firm will finely tailor our defense strategy to your case’s specific facts and circumstances, taking into account the evidence, the law, and our client’s unique circumstances, whether our client is an individual or a corporation.
If you or your business is under investigation or has been charged with healthcare fraud, contact the Rossen Law Firm immediately for a free strategy session at 754-206-6200.
Rossen Law Firm’s legal team understands what’s at stake when you’re charged with a crime in South Florida. We’re committed to defending you and protecting your rights. Our legal team is ready to create a customized strategy for your case to fight for the best possible outcome. We handle Criminal, DUI, Federal, Domestic Violence, Marchman Act & Baker Act cases, and more.
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