Healthcare Fraud Lawyer
In recent years, state and federal governments have been boosting regulation and ramping up enforcement efforts to investigate healthcare fraud cases in the country.
Federal and state prosecutors, civil enforcement officials, and Medicaid fraud enforcement authorities are becoming more creative, often relying on investigative leads from previous employees, confidential informants, and other individuals with information during the investigation and enforcement processes. As a result, seemingly minor actions may serve as the bases for fraud enforcement actions.
Healthcare fraud accusations can lead to severe consequences for any medical professional or entity. It is complex and difficult to escape, so it is crucial to have a seasoned counsel in your corner who can advise and defend you and your rights against such charges.
Mr. Serafini is a healthcare fraud lawyer based in South Florida that has prosecuted some of the nation’s most significant healthcare cases. Additionally, he has represented numerous healthcare clients in private practice.
Most Common Types of Healthcare Fraud
Billing and coding errors typically comprise a significant part of healthcare fraud cases. Sometimes, these mistakes are not deliberate; the defendant had no intent to defraud a healthcare program.
It’s also important to note that aside from hospital claims, healthcare fraud can also happen where the government pays for any type of healthcare service.
Having a healthcare fraud lawyer like Mr. Serafini, who, thanks to his experience as a former federal prosecutor (prosecuting the largest and most complex cases in federal courts throughout the country, is an excellent option) will likely be your best option to fight on your behalf.
Here are some of the most common examples of healthcare fraud and abuse.
Services Not Rendered
This form of healthcare fraud involves submitting invoices for healthcare services that were never provided. A variation of this violation is double billing, wherein a claim is submitted twice for the same service, but it was not rendered the second time.
Kickback fraud violates the federal Anti-Kickback Statute, a criminal statute prohibiting persons, laboratories, or pharmaceutical companies from offering kickbacks through monetary forms, gifts, or products to providers in exchange for referrals. This includes bonuses, research grants, referral fees, finder’s fees, travel, entertainment, excessive compensation, and cross referrals.
Ghost patients are individuals who either do not exist or who never received the item or service billed for in a claim.
Lack of Medical Necessity
Healthcare services must be medically necessary to qualify for payment by government healthcare programs. That is why healthcare providers are mandated by law to document the medical necessity of services, treatments, diagnostic tests, or medical devices for which they seek reimbursement.
Inflating Cost Reports
One common type of Medicare fraud involves hospitals or healthcare institutions inflating the costs on their Medical Cost Reports, which they are required to file to receive reimbursement for patient care.
Others falsify information on the cost reports, seek reimbursement for costs unrelated to the patient’s treatment, or manipulate statistics to maximize reimbursement.
Bundling and Unbundling
Medicare and Medicaid often give lower reimbursement rates for procedures performed together. To increase profits, some providers unbundle tests and procedures and bill each separately.
Both government and private insurance billing programs use numerical codes that identify the specific service or procedure being performed. The codes usually go from one to five depending on the complexity of the service, and each is assigned a dollar amount that the healthcare program will pay.
Upcoding happens when a healthcare provider files a reimbursement claim for services that represent a more serious and/or expensive procedure than actually rendered.
Elements of Healthcare Fraud
The elements of healthcare fraud differ based on several factors, including whether a case is civil or criminal.
The elements of healthcare fraud in federal criminal cases under 18 U.S.C. Section 1347 are:
“(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—(1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program in connection with the delivery of or payment for health care benefits, items, or services…”
Federal officials can also pursue civil or criminal charges under the following statutes and laws: Eliminating Kickbacks in Recovery Act, Anti-Kickback Statute, the Stark Law, the False Claims Act, and various other federal laws.
How to Know if You Are Under Investigation for Healthcare Fraud
If you receive the following documents, it may be a sign that you or your practice are facing a healthcare fraud investigation.
Search Warrant: If government agents execute a search warrant at your home or business, contact Mr. Serafini, your trusted healthcare fraud defense lawyer, right away. You can expect immediate advice on how you can protect your rights.
Grand Jury Target Letter: Getting a grand jury target letter is a clear sign that you are the target of a federal investigation. In this case, the government believes that enough evidence exists to convene a grand jury and seek an indictment.
Subpoena: If you receive a subpoena requiring the production of documents or compelling testimony, you should consult counsel immediately. Without adequate representation, witnesses can become subjects or targets of an investigation.
Civil Investigative Demand: This is a civil tool utilized by investigators to collect records in furtherance of a False Claims Act violation.
Medicare Suspension Letter: Medicare can suspend a provider or practice based on “credible or suspected allegations of fraud.” If you receive such a letter, you should immediately contact an attorney.
Signs of an Active Investigation
The most common means for learning of an investigation is discovery that investigators are conducting interviews. Moreover, clients often detect that they are under scrutiny for healthcare fraud when they notice signs of surveillance or learn that their patients, employees, and other potential witnesses are being investigated.
Many clients will also experience increased audits or record requests from Medicaid, Medicare, or commercial insurance carriers.
Penalties for Healthcare Fraud
Healthcare fraud can result in criminal, civil, or administrative penalties. The following is a list of potential consequences of a healthcare fraud conviction:
- Fines and penalties of up to $250,000 per offense
- Up to 10 years imprisonment
- Job loss
- Loss of board certification status
- Loss of professional license
- Forfeiture of all assets related to the alleged offense
- Exclusion from billing Medicare and Medicaid for five years to life
How Can Serafini Law Office Help?
If you or your company are in any way involved in an investigation of healthcare fraud or are facing healthcare fraud charges, the Serafini Law Office can provide you with the best representation possible.
Mr. Richard A. Serafini has 40 years of experience practicing law, and you can trust him to handle your case. He will help you understand healthcare fraud charges and formulate an effective defense strategy.
The Serafini Law Office currently offers legal services to the following cities and states: Miami, Fort Lauderdale, Boca Raton, West Palm Beach, Florida, Pennsylvania, and New York.
Contact us at (754) 223-4718 for a free and confidential consultation.