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How to Fight Back Against Healthcare Fraud Charges

Healthcare fraud is a serious crime, and if you're being investigated for potential healthcare fraud, you need to take that investigation seriously. There are many types of healthcare fraud, some of which are more severe than others, but no matter what kinds of charges you're facing, it's important to educate yourself and be ready to defend yourself.

The Basics of Healthcare Fraud

Healthcare fraud includes any type of intentional deception, misrepresentation, or act of misinformation committed by a healthcare provider or medical professional. It typically involves a violation of one or more of the following laws and statutes:

  •   False Claims Act (FCA)
  •   Anti-Kickback Statute (AKS)
  •   Physician Self-Referral Law (Stark Law)
  •   Health Insurance Portability and Accountability Act (HIPAA)
  •   Health Care Fraud Statute (18 U.S.C. § 1347)
  •   Controlled Substances Act
  •   Medicare and Medicaid Laws

Common examples of healthcare fraud include:

  •       Providing unnecessary services. You can be accused of healthcare fraud if you provide unnecessary services to your clients. Typically, doctors and medical professionals who commit this crime do so to increase revenue, but it can also increase risks for the patient.
  •       Billing for unrendered services. Similarly, healthcare fraud includes billing for unrendered services. In this scenario, you'll include line items on invoices for products and services you never actually distributed.
  •       Double billing. Sometimes, health care fraud investigations look into instances of double billing – in other words, billing a patient twice for the same service.
  •       Phantom billing. Healthcare fraud can also manifest as phantom billing, or billing fictional patients for unrendered services.
  •       Upcoding and/or unbundling. Upcoding a service means coding it differently so you can bill an insurance company a higher amount. Unbundling means billing individual services that should be grouped together.
  •       Kickbacks and referral schemes. Receiving undue financial incentives and other gifts in exchange for recommending products or services can be considered fraudulent.
  •       Record falsification. Issues with medical record falsification can also count as healthcare fraud. There are many possible motivations to lead a person to record falsification.
  •       Credential fraud. Fraudulently presenting your credentials also counts as healthcare fraud.
  •       Forgery and identity theft. In some cases, we also see elements of forgery and identity theft in play.
  •       False diagnoses. Providing a patient with a false diagnosis to recommend specific services to them is another example of healthcare fraud.
  •       Prescription drug fraud. Any fraudulent action related to prescription drugs, such as recommending unnecessary drugs, double billing for these drugs, and so on, can also qualify.

Are You Under Investigation for Healthcare Fraud?

You'll likely know pretty quickly if you're under investigation for healthcare fraud. In most cases, you'll receive direct contact from law enforcement, or agencies like the FBI or HHS. You may also have interview requests, subpoenas or warrants against you, and advanced notice from regulatory authorities and insurance companies. It's also a good idea to pay attention to media coverage and potential whistleblower actions.

How to Fight Back Against Healthcare Fraud Charges

If you are facing healthcare fraud charges:

  •       Hire a lawyer. It's important to hire a lawyer as soon as you realize you're under investigation for healthcare fraud. They can help you better understand the charges against you and help you prepare a defense.
  •       Stay quiet. As much as possible, stay quiet during the investigation. Don't provide unnecessary details to investigators, follow the advice of your lawyer strictly, and avoid making public comments about the case.
  •       Gather evidence. You can also start gathering evidence that may be able to weaken the case against you.

Together with your lawyer, you may be able to mount a defense by demonstrating:

  •       Mistakes/errors. If the problematic situation is due to an innocent mistake or error, it cannot be considered fraudulent. The difficulty is in proving that this action was a total mistake, which can be difficult, especially if the action benefits you.
  •       Lack of intent. Similarly, you may be able to demonstrate a lack of intent. Fraud demands intent.
  •       Insufficient evidence. There may simply be insufficient evidence against you. If the prosecution doesn't have enough material to work with, it could work in your favor.
  •       Lack of damages. You may also be able to get the charges dropped if you can show that there's a lack of damages; in other words, you'll need to prove that the instance of fraud caused no real harm.
  •       Entrapment. In some cases, you can demonstrate entrapment. In this scenario, you would need to prove that law enforcement officers set you up to do something you wouldn't have otherwise done.
  •       Selective prosecution. Some defendants pursue defense by demonstrating selective prosecution, showing the system is unfairly against them.
  •       Violation of your constitutional rights. If your constitutional rights were violated during the investigation, it can severely weaken the case against you or even get the charges dropped.
  •       Duress or coercion. In very rare cases, you can demonstrate that you only operated under duress or coercion.
  •       Statute of limitations. A statute of limitations is a law imposing a time limit on when charges for a given offense can be filed. If the statute of limitations has passed, the charges will be dropped.

Facing healthcare fraud charges can be very stressful. After all, your entire career could be on the line. But with the help of a good lawyer and some extra evidence on your side, you can find yourself in a much better legal position.