Health Care Fraud

Health care fraud is a growing phenomenon in Florida and nationally. The Office of Inspector General (OIG) for the U.S. Department of Health and Human Services reports in a single recent fiscal year, the federal government recovered $3.3 billion in health care fraud judgments and settlements. That same year, federal investigators opened nearly 1,000 new cases of criminal health care fraud, and some 800 defendants faced federal charges.

At The Ansara Law Firm, our criminal defense attorneys in Fort Lauderdale are committed to helping those accused of health care fraud to fight back against the devastating impact a conviction might have.

Health care fraud encompasses a wide range of fraudulent activity that could be committed by patients, insurers, providers and sometimes third parties.

18 U.S. Code Section 1347 defines health care fraud as perpetrated by anyone who knowingly and willfully executes or attempts to execute a scheme that knowingly defrauds a health care benefit program or obtains – by means of false pretenses/ promises/ representation – money or property of any health care benefit program.

Some examples of health care fraud by a provider may include:

• Billing for services that weren’t performed;
• Falsifying patient diagnosis to justify surgeries, tests or other procedures that aren’t medically necessary;
• Falsely representing procedures performed to obtain payment for non-covered services;
• Taking kickbacks for patient referrals;
• Upcoding (billing for more costly services than what were actually performed);
• Waiving co-pays or deductibles from patients and then over-billing insurers or benefit plans;
• Billing patients more than the copay for services pre-paid or paid in full by insurer;
• Offering products or treatments that claim to prevent, treat or cure health conditions when they are not proven safe and effective for those uses.

Some examples of health care fraud by consumers:

• Filing false claims for services they never received;
• Altering or forging receipts or bills;
• Using another person’s insurance card or coverage;
• Making false statements on applications or contracts to participate in Medicaid or Medicare programs.

Some examples of health care fraud by third parties include:

• Obtaining patient insurance information to use it for their own benefit;
• Equipment manufacturers that offer “free” products to individuals, when in fact, insurers are being billed for them (particularly when those products were not needed and may not have been delivered);
• Unnecessary and sometimes falsified tests given to health clubs, retirement homes or shopping malls that are then billed to insurance or Medicare providers.

It’s important to point out that the statute specifically says one need not have actual knowledge of the law or specific intent to commit a violation of this section to be convicted.

The OIG reports these actions collectively cost tens of billions of dollars annually. In recent years, the FBI has been teaming up with local authorities to crack down on these activities, and it has meant an uptick in health care fraud arrests and convictions.

The most serious penalty for a federal health care fraud conviction in Florida is a maximum of 10 years. In the event someone suffers serious bodily injury due to the fraud, one can be imprisoned for up to 20 years. If someone dies, it can result in a life sentence upon conviction.

There are numerous other offenses that can be charged along with this that also carry severe prison terms. For example:

• Conspiracy to commit health care fraud – 20 years in prison
• False Claims Act violation – maximum 5 years per occurrence, or life if convicted on numerous counts
• Money laundering – maximum 10 years in prison
• Conspiracy to commit money laundering – maximum 20 years in prison
• Wire fraud – maximum 20 years in prison

On top of this, there are numerous civil fines that may be ordered. A conviction for health care fraud, for instance, carries a maximum $250,000 fine. Anti-Kickback Statute violations carry a penalty of either $50,000 per violation or three times the size of the kickback – whichever is bigger. Violations of the False Claims Act can carry a penalty of $21,500 per claim or three times the amount of damages the government sustained.

Finally, professionals can incur:

• Loss of license;
• Loss of DEA registration;
• Exclusion from Medicaid and Medicare programs;
• Suspension of payment for outstanding invoices;
• Loss of staff privileges.

At the state level, one can be charged with:

• Medicaid provider fraud, F.S. 409.020, a third-degree penalty punishable by maximum five years in prison (if under $10,000) or a second-degree felony punishable by 15 years in prison (if between $10,000 and $50,000) or a first-degree felony punishable by 30 years in prison (if more than $50,000).
• False and fraudulent insurance claims, F.S. 817.234, generally a third-degree felony punishable by a maximum 5 years prison, though some cases may be increased to a second-degree felony with a maximum 15 years and a minimum mandatory two-year prison term.

If you are accused of health care fraud in South Florida, our dedicated white collar crime criminal defense lawyers in Fort Lauderdale can help.

If you have been arrested for health care fraud in South Florida, contact the Fort Lauderdale Criminal Defense Lawyers at The Ansara Law Firm by calling (954) 761-4011.