“Lawyer for Healthcare Fraud Defense” is a team of federal attorneys with the objective of preserving your legal health rights and financial assets. We are posed to help you get through the storm of injustice and the wrong of being ‘more successful’ than the others.
Are you among the blessed yet unfortunate few who have been wronged because of wealth? Sometimes, the government is responsible for this unjust treatment because you have a few bucks. You have put in a great deal of effort to establish your company; you have given back to the community and improved patient care; you have never had any criminal intent; you have created jobs for your vendors and employees; you pay high taxes to ensure that everyone else benefits; and now the government is threatening to undo all that you have worked so hard to achieve.
Get in touch with our defense team. Never surrender. Contact us to get things fixed.
Lawyer for Healthcare Fraud Defense: Is there healthcare fraud?
A healthcare fraud trial usually revolves around the accused’s intent. In many cases, the government’s case against the accused is heavily reliant on billing and coding errors; however, the mere existence of such errors does not prove that the defendant had the necessary intent to deceive a medical insurance program. A scheme to prey on a healthcare program typically involves false or deceptive representations intended to acquire something of value—usually money.
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Lawyer for Healthcare Fraud Defense: Types of Healthcare Fraud?
Proof of Burden
When someone is charged with healthcare fraud, the burden of proof is on the government to demonstrate that the defendant participated in a scheme to embezzle money from a medical program, such as Tricare, Medicare, Medicaid, the Department of Labor, or any other public or private insurance scheme.
As can be seen, the phrase “healthcare fraud” is broad and covers a range of actions intended to defraud a provider of money while harming the federal or state governments. While not all examples of fraud are included, the list below enumerates some of the most prevalent ones.
Federal Anti-Kickback Statute
A criminal law known as the federal Anti-Kickback Statute forbids individuals or organizations from knowingly and deliberately soliciting, accepting, providing, or paying compensation for referrals of goods or services that are payable to government healthcare programs, including Medicare, Medicaid, and Tricare.
The purpose of this statute is to stop fraud and misuse. Referral fees, finder’s fees, bonuses, subsidized leasing, research grants, exorbitant compensation, and trips or entertainment are all covered by the Anti-Kickback Statute.
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Services of Upcoding
Government healthcare initiatives assign a dollar amount for each necessary procedure; billing for both private and public insurance programs uses numeral codes that recognize the specific procedure or aid being provided. Up-coding is a type of healthcare fraud in which a medical facility submits claims for services that are more expensive and/or more serious than the actual procedure that was performed. Up-coding may also be an offense under the False Claims Act.
Not Rendered Services
Health care fraud involves filing claims for medical services that were never provided, a practice known as billing for services never supplied.
Ghost Patients
Claiming medical services from “ghost patients,” or patients who are either nonexistent or never received the item or service that was billed for in the claim, is a type of health care fraud.
Tempered Cost Report
Medicare pays hospitals and other healthcare facilities a portion of the costs associated with treating specific individuals. Medicare requires these hospitals and healthcare facilities to submit cost reports.
In order to maximize Medicare reimbursement, hospitals and other healthcare facilities have been known to inflate charges or falsify information on their Medicare cost reports. This is a typical kind of health care fraud. Examples of cost report fraud include increasing patient care costs erroneously, requesting reimbursement for expenses unrelated to patient care, requesting reimbursement for expenses incurred by patients who are not covered by Medicare, and incorrectly altering statistics.
Medicare Fraud
The American Medicare Prescription Drug, Improvement, and Modernization Act, passed by Congress in 2003, introduced “Part D” to the Medicare Program.
Prescription medication coverage and premiums are included in the Part D program. It is anticipated that in the years to come, there will be significant fraud targeting the Part D program since its introduction. Claims of duplicate billing, overcharging, enrollment fraud, red-lining, and improper reimbursements from pharmaceutical producers and distributors are examples of Medicare Part D fraud.
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Lacking Medical Facilities
Medical necessity is a requirement for healthcare services to be eligible for reimbursement under government healthcare programs. Legally speaking, providers must attest to the medical relevance of any procedures or services they are requesting payment for. One prevalent kind of health care fraud involves submitting claims for procedures, diagnoses, treatments, and medical equipment that are not considered medically necessary.
False Finance Ratings
Medical professionals and other healthcare professionals are prohibited from having a financial stake, either directly or indirectly, in certain services that they give to their patients by both state and federal regulations.
The federal Stark Law, 42 U.S.C. 1395nn and 1396b, is an illustration of this. A doctor is not allowed to refer a patient for any certain authorized health aid to an organization in which they own stock, have an investing interest in, or have a pay arrangement with, according to the Stark Law. The Stark statute also addresses payments made to any member of the doctor’s immediate family for investments and other benefits. The False Claims Act may also be broken by breaking the Stark Law or equivalent federal regulations.
Fake Certification
When submitting charges to government health care systems like Medicare, Medicaid, and Tricare, medical professionals, hospitals, and other healthcare providers must have specific credentials on hand. These certificates cover real performance, medical necessity, and regulatory conformity.
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Furthermore, in order to be eligible for government healthcare programs, healthcare providers must fulfill all of their contractual obligations to the government. Healthcare fraud, including potential violations of the False Claims Act, can occur when such certifications are falsified in an attempt to receive payment for a medical claim or to secure further business.
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Lawyer for Healthcare Fraud Defense: How can cases be resolved?
In the majority of healthcare fraud instances, a doctor or a healthcare organization (lab, pharmacy, hospital, or health care agency) is thought to have submitted false billing claims to either Medicare, Medicaid, Tricare coverage, or a private insurance firm.
In an industry renowned for its regulatory intricacy, billing errors are not unusual; therefore, in order for the government to become involved, the supposed fraud must be extensive, well-organized, and financially substantial.
When the amount of reimbursement that is obtained is in the tens or hundreds of thousands of dollars, then mistakes in billing are financially significant. The term “fraud” is quite nebulous, and typically, the government will assert that a healthcare treatment was not medically necessary, did not follow established protocols (such as doing unnecessary tests), was overcharged, or was charged for but not rendered.
A medical care audit inquiry, a CID (Civil Investigative Demand), a subpoena from the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS), a request for evidence from a grand jury from the Department of Justice (DOJ), or, if the case has already advanced, a federal search warrant or an indictment for your company are all indications that you or your company are under investigation. A skilled lawyer will be able to see the subtle differences in each of these cases and craft a defense plan just for them.
Lawyer for Healthcare Fraud Defense: What to Know?
Act of false claim
The majority of FCA cases start out as leaker incidents. That is, a person files a lawsuit in an attempt to later receive compensation after reporting suspected fraud to the authorities; this person is frequently an ex-staff member or a rival.
The targets of these whistleblower lawsuits frequently become aware that an investigation is underway when they receive a government subpoena (such as an OIG subpoena) or a Civil Investigative Demand (CID) requesting records and company information. Making sure that the probe does not result in a criminal case is the first priority in each of these defense situations.
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Theft of Identity
Severe identity theft serves as an excellent example of why it’s critical to have reputable, knowledgeable healthcare fraud defense lawyers on your side. The Justice Department has begun to supplement indictments for healthcare fraud with counts of aggravated identity theft. There is a mandatory two-year prison sentence for each count. Probation is therefore not a possibility. We saw this trend early on and have successfully argued that the case does not qualify as aggravated identity theft, sparing our clients from years of needless incarceration.
Federal Agent Conspiracy
Physicians and others are the targets of several federal healthcare fraud charges that are filed as conspiracies. In essence, the government asserts that numerous individuals have made contributions to the overall prosperity of a fraudulent operation. Consider the following scenarios: a doctor (D), a pharmacy (P), and a marketer (M). All three people could face conspiracy charges if M gives D illegal incentives to send referrals to the pharmacy (sometimes known as “kickbacks”).
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The marketer could face charges for bribery, the doctor could face charges for taking the bribe, and the pharmacy could face charges for billing claims that were founded on kickbacks. This chain is breakable. Give us a call right now to find out how we were able to successfully fight against numerous conspiracy accusations!
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