Different Types of Health Care Fraud

Illionois defense attorney,  Illinois criminal defense lawyerHealth care fraud is considered a white collar crime, but it can come with very serious penalties. Doctors and healthcare workers typically think of this type of fraud as stealing from a government healthcare program, such as Medicare. The government, however, sees it very differently. To prosecutors and federal agents, even small errors are considered fraud, and allegations that can be proven will result in strict penalties, including loss of program eligibility.

It is important that anyone working in the healthcare industry understands just how broad health care fraud is. Below are ten of the most common types of healthcare fraud.

Inaccurate Billing and Coding

Of all the different types of healthcare fraud, inaccurate billing and coding procedures are some of the most common. Double-billing a healthcare program, billing for costs not applicable under a program such as operational expenses, and billing for services at stand-alone rates rather than bundled rates are all examples of this type of healthcare fraud.

Even an unintentional mistake when applying for reimbursement from a government program is often enough to have an individual or organization charged with healthcare fraud. Penalties for committing this type of fraud include a minimum fine of $21,000 for every false claim, additional fines, and loss of eligibility for the program.

Kickbacks

The federal Anti-Kickback Statute makes it illegal for any healthcare provider to knowingly and willfully offer or receive any funds from a federal healthcare program in order to procure a purchase, lease, or patient referral. It is important for healthcare workers to understand that while the law states this kickback must be taken or received ‘knowingly or willfully,’ that is not always the case. Like billing and coding errors, if a mistake was made that affected funds from the federal program, healthcare institutions can be prosecuted.

The term ‘knowingly and willfully’ is not the only confusing terms within this statute. There are exceptions to this law that are also not as clear. Compensation to W-2 employees, some risk-sharing and purchasing agreements, and safe harbors for certain transactions are just a few examples. A healthcare fraud lawyer can help healthcare organizations understand what is and is not a crime.

Physician Self-Referrals

Many areas of healthcare fraud law apply broadly to many different healthcare organizations and workers. The law pertaining to physician self-referrals applies only to doctors. This law is also known as the Stark Law. Under this law, doctors cannot refer a patient to another doctor or health service in which the referring doctor has a financial interest.

False Claims

While there are many different types of healthcare fraud, making false or fraudulent claims is one of the broadest. The False Claims Act makes it illegal for anyone to purposefully make false claims when applying for reimbursement from any federal health care program. This can include billing and coding errors, illegal forms of remuneration, and more. Those found in violation of the Act can face both criminal and civil penalties.

Billing for Unnecessary Services, Supplies, or Equipment

Federal healthcare programs are in place to provide doctors with necessary services, supplies, or equipment so those doctors can then give their patients the best treatment. In cases when a healthcare worker provides inpatient treatment beyond the length of stay Medicare approves, prescribes medications to treat a condition that does not require a prescription, or provides healthcare services in a facility when a lower-cost facility was available, these are all considered to be unnecessary billing practices.

Billing for Services, Supplies, or Equipment Not Provided

Just as healthcare workers cannot provide services or equipment that is unnecessary, they are also forbidden from doing so when those services are not actually provided to patients. This practice is also known as phantom billing due to the fact that healthcare workers are billing federal agencies for items never passed on to patients. Sometimes this is done intentionally by a healthcare organization but more often than not, it is a simple mistake with big consequences.

Prescription Drug Fraud

Prescription drug fraud has garnered a lot of attention in the past few years due to the opioid crisis. This crime can include falsifying prescriptions, selling fraudulent prescriptions, prescribing medications without first examining a patient, and more.

Falsifying Patient Records and Test Results

When the federal prosecution charges a healthcare worker or organization with falsifying patient records and test results, they will argue the worker did so in order to increase their profit or the profit of the facility. The truth is though, that many times there is no falsification. The records of one facility are simply far above national or regional averages. This happens more than people think as this crime relies heavily on data analytics.

Fraudulent Physician Certifications

This may sound like a crime in which a doctor falsifies their own certificate from medical school or other institution. However, it is not. Instead, this crime refers to beneficiaries of Medicare or other healthcare programs that require home health or hospice care. These patients must be certified every 60 days and that certification requires a physician to perform a full examination. Once the exam is finished, the physician then needs to certify that the patient still requires home care. When that certification is falsified, it is a crime.

Problems with Election Statements for Hospice Care

Just as hospice care patients need to be certified, they also need to sign an election statement. Within these statements, the patient will acknowledge that they have received complete and accurate information about the nature of hospice care and that they have waived their rights to Medicare coverage for treatment not provided by the hospice provider. In order to be protected from this law, hospices should always keep all election statements from their patients.

Healthcare Workers Need the Illinois Federal Criminal Defense Lawyer that Can Help

Being charged with healthcare fraud is very serious. Healthcare workers can expect large fines, and could even have their license taken away. It is for these reasons that anyone accused of healthcare fraud needs the experience of a passionate Chicago federal criminal defense lawyer. If you are facing healthcare fraud charges, let the Law Offices of Hal M. Garfinkel help you beat them. We know the many laws pertaining to healthcare around the country, and we know the defenses that can be used for them. We also know that simple, honest mistakes can cost healthcare workers dearly. Call us today at 312-270-0999 for your free consultation.

Sources:

https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

https://www.govinfo.gov/app/details/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXI-partA-sec1320a-7b

https://www.law.cornell.edu/uscode/text/42/1395nn

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