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Understanding Healthcare Fraud

Healthcare fraud is the filing of false healthcare claims. It is easier than you think to be accused of this crime. Auditors, patients, members of your staff, and others can easily mistake proper billing for a crime.

If you have been under investigation or arrested for healthcare fraud, your first response should be to contact a lawyer. Being charged with healthcare fraud is not the same as being guilty of it. You are innocent until proven guilty, and you must act quickly to protect your rights.

Because healthcare fraud cases can be complex, it is important that you say nothing to the authorities until you have spoken to an attorney. Your lawyer will advise you as to whether you should answer questions by government auditors or investigators.

What Is HealthCare Fraud?

Healthcare fraud is a serious crime. If you are convicted of healthcare fraud, you will face a long term of incarceration and will be banned from federal and state healthcare programs. In addition, a fraud conviction usually results in the loss of professional licenses that will prevent healthcare providers from continuing to practice their profession.

Here are some of the most common types of behavior that come under the category of healthcare fraud:

  • Performing medically unnecessary services and then billing for the unnecessary service
  • Accepting money or other things of value for patient referrals
  • Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary
  • Billing for services or products that were never rendered or provided
  • Billing for more expensive services or procedures than were provided or performed, known as upcoding
  • Billing each step of a procedure as if it were a separate procedure
  • Over-billing or upcoding

These are just some of the acts for which can result in a healthcare fraud prosecution.

Further Impacts of a Healthcare Fraud Charge

The impact of a conviction can negatively impact your entire life. Your professional and societal reputation could be ruined. Your family could also be made to suffer the consequences of your conviction in the form of harassment, unwelcome notoriety, loss of income, as well as incarceration of the family’s principal income earner.

If you are a licensed healthcare provider such as a doctor, pharmacist, dentist, or physician assistant, you may lose your license. If you are a healthcare executive, you might find it impossible to return to the industry even after you have served your time in prison. In short, your professional life as you knew it—all that you have worked for and strived to achieve—will be brought abruptly to an end.

Healthcare Fraud as a Federal and State Crime

Healthcare fraud is a federal as well as state crime and will, thus, be investigated and prosecuted by federal as well as state authorities. In Florida, the Attorney General and the state-wide prosecutor’s office investigates healthcare fraud including Medicaid fraud. The federal government utilizes the FBI as well as other law enforcement agencies that work with the Department of Justice.

Federal agencies have the tools and resources of the entire federal government at their disposal. The people investigating your case will be able to employ extensive investigative manpower, the most sophisticated methods and techniques of collecting and analyzing information, and an army of legal talent to work through your case. State healthcare fraud investigators and attorneys are specialized in detecting healthcare fraud. These state investigators are not local police personnel.

How an Experienced Federal Crimes Attorney Can Help

If you are under investigation or have been arrested and charged by federal or state authorities for healthcare fraud, your first move should be to engage the services of an experienced healthcare fraud defense attorney who has dealt with state and federal healthcare fraud cases. You need a criminal defense attorney who understands how investigations and prosecutions work. You will need their insight and guidance if you are to get through this difficult process.

Your federal crimes attorney will need to hear your side of the story. During the first consultation, they will ask you to recount your view of the circumstances which have led to the investigation by law enforcement.

Federal and state prosecutors can make mistakes and come to the wrong conclusions of your guilt. You may be associated with or have had dealings with someone who has committed healthcare fraud. This is one of the many ways of becoming a target of such an investigation. The state and federal governments also examine healthcare billing practices such as over-utilized procedures. Statistics of the number of procedures may cause investigators to believe fraud is present. Such a conclusion is not necessarily correct. What appears to be fraud by government investigators may be mistakes in billing or coding.

It is the job of your criminal defense attorney to scrutinize every piece of evidence the federal or state investigators have developed to prepare a defense. Private investigators and healthcare experts may be utilized to overcome the incorrect assumptions held by the investigators.

Even if you made a mistake in your billing, that doesn’t mean you are guilty of a crime. By retaining an experienced healthcare fraud defense attorney at the early stage of the federal or state investigation, your attorney may be able to show the prosecutor that there was no fraud. For example, incorrect billing may be due to innocent mistakes; not fraud. It is also possible that the investigators may be incorrect in their conclusion that the CPT or diagnose code used was wrong. Likewise, statistics which reveal that a healthcare provider bills a larger number of certain procedures may be explained by the nature of the practice and the type of patient in a geographic area.

If you are under investigation or charged with healthcare fraud, you have no time to waste. You need legal representation straightaway. The experienced attorneys at the Law Offices of Horwitz & Citro, P.A. have over 45 years of collective experience handling criminal defense cases across the United States.

Contact Law Offices of Horwitz & Citro, P.A. at (407) 901-5852 for aggressive legal advocacy.