Every year, billions of dollars are wasted due to healthcare fraud, drastically inflating the costs of medical care and health insurance. But the fallout extends beyond mere financial burdens—healthcare fraud can also result in unwarranted penalties, damaged reputations, and even potential imprisonment for those entangled in this type of fraud.
This article examines how to protect yourself against such damaging accusations. This is not only a must-read for those involved in the healthcare sector but everyone else, as being equipped with knowledge and precautions is your first line of defense against the effects of healthcare fraud.
If you find yourself wrongfully accused of healthcare fraud, there are several important steps to follow. First, evaluate your billing records for possible mistakes or inaccuracies. Next, gather all relevant documentation that can demonstrate false charges and support decisions made regarding medical services. Lastly, it is crucial to collect any additional records or evidence that can help refute the accusations.
With over 40 years of experience practicing law, Mr. Richard A. Serafini is a federal criminal defense lawyer who can help you through the process.
Understanding Healthcare Fraud
Healthcare fraud comprises various illegal activities that can have significant consequences for patients, insurance providers, and the healthcare system at large. Essentially, these usually involve false billing or otherwise misrepresenting facts related to medical services rendered to patients.
For instance, a doctor might bill for tests never conducted or exaggerate the treatment necessary for a patient’s condition. Similarly, a healthcare professional could intentionally omit information regarding insurance coverage to inflate prices or conceal the fact that he is performing procedures outside of legal licensure.
The criminal and civil prosecution is an area of emphasis for many federal and state law enforcement agencies:
- According to the National Health Care Anti-Fraud Association, the U.S. loses tens of billions of dollars each year due to healthcare fraud.
- The Association of Certified Fraud Examiners reported in 2020 that about 6% of all healthcare expenses are lost to fraudulent practices.
- As per the U.S. Department of Justice records, in 2019 more than $2.6 billion was recovered from businesses and individuals in settlements related to false claims against federal healthcare programs.
Manifestations and Examples of Healthcare Fraud
The manifestations of healthcare fraud are diverse, but some seem more common than others. One is upcoding, whereby medical billing codes are manipulated to reflect higher-level procedures than actually performed. A physician involved in this type of wrongdoing might claim to have performed complex surgical procedures instead of simpler actions. In another example, healthcare service providers may bill multiple times for distinct hospital rooms when their patients receive all treatments in one place.
Another type of healthcare fraud is unbundling, when charges are unnecessarily itemized and billed as separate events. This could include breaking down fees into categories such as medical procedures, adaptive equipment, and medication, even when contra-indicated.
| Type | Description |
| Phantom Billing | Billing for non-existent patients or services never provided |
| Double Billing | Charging more than once for the same service |
| Overcharging | Charging more than fair-market value or previously negotiated amount |
| Kickbacks | Paying any remuneration for referrals or to incentivize decisions |
| False billing | Falsifying records or overstating costs |
Healthcare fraud is not only illegal but also attracts severe consequences that must be avoided at all cost.
Legal and Professional Consequences of Healthcare Fraud
Healthcare fraud is a serious federal crime that comes with severe legal and professional consequences. If convicted, individuals found guilty of healthcare fraud may face imprisonment for many years, along with substantial fines and restitution charges. In addition to these criminal penalties, healthcare providers could potentially be excluded from government insurance programs and lose their medical license as well as their right to practice in the future.
For instance, suppose a physician commits healthcare fraud by billing Medicare for procedures never performed. In such cases, that physician could be found guilty of fraudulent activity and incur both legal and professional consequences. This could lead to losing medical license, facing imprisonment, significant fines, and permanent damage to the physician’s career.
The best strategy for dealing with healthcare fraud allegations is to hire an experienced federal criminal attorney such as Richard Serafini, who can advise on the best approach and protect your legal rights.
Financial Penalties and License Revocation
Individuals convicted of healthcare fraud may also face financial penalties in addition to serving jail time or probation. Courts typically order defendants to pay restitution as a means of reimbursing victims for damages incurred due to their actions.
Furthermore, defendants who hold professional licenses – such as physicians or nurses – might lose the ability to practice in their profession if they are found guilty of healthcare fraud. Losing licensure could have devastating financial implications for professionals as they would no longer be able to generate income.
It is noteworthy that not all instances of erroneous billing constitute healthcare fraud. Honest accounting errors or mishandling claims do happen, but what distinguishes these from fraud is intent. Did the accused intend to defraud insurance providers? The intention could be challenging for the prosecution to prove beyond reasonable doubt.
Actions To Take if Accused of Healthcare Fraud
Accusations of healthcare fraud can be a harrowing experience, but it is essential to remember that the accusations themselves do not equate to guilt. The best approach is to follow specific steps to mitigate the ultimate impact of the investigation:
First, it is advisable to take a deep breath and get in touch with experienced legal counsel. Legal counsel will evaluate the case’s merits and help guide you appropriately.
Suppose you are an optometrist accused by Medicare of overbilling for services. In that case, you would want to contact an attorney specializing in defending against healthcare fraud charges. It is a smart move as this could well make or break your defense.
Next, prioritize preserving all relevant documents and billing records related to patient care. Assembling all documents like claims and payments made will be crucial; these documents can serve as evidence in your favor when facing any investigations or court hearings. Moreover, destruction of such documents could well lead to an obstruction of justice criminal charge.
Assessing Billing Records and Gathering Documentation
Assessing billing records and gathering appropriate documentation is necessary for developing a defense strategy against allegations of healthcare fraud. Reviewing your billing records for possible mistakes can aid in determining discrepancies or inconsistencies that may harm your case. In some cases, retaining an expert in the area of medical billing is advisable.
Counsel should determine whether a government audit itself may have had errors or unintended mistakes that have led to accusations of fraud; this is where detailed record-keeping comes into play. By meticulously organizing these crucial documents, you also set yourself up for success during audits or investigations.
For example, suppose there is a pediatrician facing claims from insurance providers regarding duplicate billing for procedures –one way to defend the case could be through assessing your records and identifying potential coding errors related to the procedures that insurers wrongfully considered duplicates. This is important in establishing lack of the necessary intent for conviction.
While assessing billing records and gathering documentation is just one step in defending against healthcare fraud allegations, appropriate record-keeping and thorough analysis can make a difference in addressing these accusations successfully.
Navigating Investigation and Legal Proceedings
If you find yourself in a healthcare fraud case, it is essential to know how to navigate investigations and legal proceedings. The first thing you should do is to hire an experienced attorney who has experience in healthcare fraud investigations and cases. Knowing your rights and best practices during investigation is crucial to ensure that you do not incriminate yourself and receive the best possible defense.
Rights and Best Practices During Investigation
When under investigation for healthcare fraud, it is essential to know both your constitutional and statutory rights. Remember that you have the right to remain silent – this means that you do not have to talk with investigators. The best practice is to politely decline an interview, obtain contact information from the investigator, and retain experienced counsel, providing the agent’s contact information to the attorney. Also, understand that any information provided can be used against you, so refrain from providing a statement. Sometimes, seemingly innocuous statements become important elements of the prosecution’s case.
Also, never lie to investigators as lying during interrogations worsens your case and can lead to additional charges. An individual may always refuse an interview with investigators; however, if one chooses to be interviewed, provide truthful information. The better practice, as stated above, is to contact a lawyer to provide counsel regarding making any representations to investigators. Also, of primary importance is to be candid with your attorney and provide him or her with complete information.
Additionally, when investigators execute search warrants or subpoena documents, contact experienced counsel immediately. These are legal actions that compel compliance. Nevertheless, even in the cases of a search warrant or a subpoena, no one is required to submit to an investigative interview. These are significant investigative events, and individuals experiencing them should immediately contact counsel. Moreover, in these circumstances always obtain a copy of warrant or subpoena to discuss with your attorney. This should not be problematic as agents are required to present copies of search warrants and subpoenas.
Are You Being Investigated for or Charged with Healthcare Fraud?
If you are being charged with healthcare fraud or are involved in a healthcare fraud investigation, the Serafini Law Office can provide you with the best representation possible. Our team will work tirelessly to protect your freedom, rights, and reputation.
Mr. Richard A. Serafini is a defense lawyer who has been practicing law for over 40 years.
He is a former senior prosecutor with the U.S. Department of Justice and supervisor with the U.S. Securities and Exchange Commission. At DOJ he prosecuted some of the largest healthcare fraud cases charged by the United States. With his vast knowledge and experience in investigations and criminal law, he is the person you need to formulate an aggressive strategy to help you achieve the best results.
Our law firm offers representation in criminal defense throughout the United States and particularly in 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 consultation.