Health care fraud is a serious offense that involves the deliberate submission of false claims or making false statements in connection with health care reimbursement. The government can build a case for this type of crime against health care providers, patients, and other entities.
#1: What will trigger an investigation?
There are many forms of health care fraud. Prosecutors often pursue charges related to the following:
- Billing for services that were never provided to the patient,
- Upcoding services to increase the reimbursement provided,
- Performing procedures that are not medically necessary to increase billing,
- Falsifying patient records to justify claims, and
- Soliciting or receiving kickbacks in exchange for patient referrals.
Penalties are severe. Individuals or facilities who are convicted or negotiate a settlement for these allegations can find themselves facing millions of dollars in fines and restitution payments as well as potential imprisonment.
#2: What are the laws?
There are many rules and regulations that guide practices within the medical field, but two that the government often uses to support allegations of health care fraud include the False Claims Act (FCA) and the Anti-Kickback Statute (AKS). The FCA imposes liability on individuals or entities that knowingly submit or cause the submission of false or fraudulent claims to the federal government while the AKS prohibits exchange of remuneration for referrals of services paid for by the federal health care programs.
#3: How can I defend myself against accusations of health care fraud?
Various legal strategies are available, and the best fit will depend on the details of the case. Examples can include a challenge to the prosecution’s evidence of intent to defraud or demonstration of the medical necessity of services provided. Medical professionals could also argue that they used the appropriate billing code for the services rendered.
Health care professionals are wise to understand the legal implications of health care fraud. Awareness and compliance with health care laws are essential to avoid the severe penalties associated with these offenses. Those who face these allegations are wise to seek legal counsel experienced in health care law to help navigate the complexities of defense in health care fraud cases.