Insurance fraud can result in a civil lawsuit or a criminal prosecution. Insurance fraud can take on many forms, from false claims on a homeowners policy to complex issues of billing for medical services. Many doctors and health care providers find themselves subject to civil or criminal investigation as a result of mistakes relating to complex billing and medical coding issues.
Doctors and other health care providers have been targets of an increasing number of investigations and prosecutions for insurance fraud. Attempting to curb rising health care costs, the government has placed billing practices under higher scrutiny. We have defended professionals charged with fraud involving allegations of billing for services not given, double billing, billing for services not medically necessary, fraudulent coding and upcoding, and kickbacks.
Besides prosecuting health care professionals, the government also charges individuals with insurance fraud for arson, theft, and faking accidents. You also may be charged under the RICO Act, and face serious criminal and civil sanctions. If you are under investigation or charged with insurance fraud, it is wise to speak to an experienced Orlando criminal defense lawyer immediately.
Every state has its own agency governing Medicaid, and each state has a corresponding criminal investigation arm. Many Medicaid fraud cases originate through statistical studies of billing procedures that trigger a civil audit, with devastating consequences for providers who have done nothing illegal.
An innocent error in billing or a pattern of suspicious bills can quickly lead to criminal investigation by a host of state or federal agencies. If you or your company has been questioned or indicted, contact an experienced Orlando Medicaid fraud defense law firm.
Charges often start with Medicaid fraud investigation units in each state scouting for red flags in CPT and ICD-9 coding on Medicaid reimbursements. Suspicious billing is then referred to the state Attorney General's office for an official civil audit. In other cases, the hint of fraud is uncovered by a federal agency or a private insurance company, with the help of industry associations dedicated to fraud investigation.
The complexities of the Medicare bureaucracy make it difficult to bill properly and easy to run afoul of fraud laws. An honest mistake in billing can trigger a civil audit and can quickly turn into a criminal investigation nightmare.
We understand the convoluted Medicare billing system and how innocent, but mistaken, billing practices lead to the assumption of fraud. State and federal agencies monitor CPT and ICD-9 codes for patterns outside the norm — excessive billing or codes that don't match the reported services. A routine audit can easily become a full-scale criminal investigation by the FBI or state authorities.
Private insurance companies take health care fraud seriously. It affects their bottom line, and they devote enormous resources to tracking down perpetrators to recover their losses. At the Law Offices of Horwitz & Citro, P.A., we represent clients in civil audits, criminal prosecutions, and civil litigation arising from allegations of bilking private insurers involving alleged conduct such as:
Private insurance companies have their own fraud investigation units (e.g., the Blue Cross/Blue Shield Bureau) trained to detect patterns of subtle over-billing as well as outright fraudulent claims. The industry also shares information and resources through the National Insurance Crime Bureau and the National Health Care Anti-Fraud Association. If they believe fraud has occurred, insurers coordinate with state and federal law enforcement agencies to initiate criminal investigations.
Private insurance companies can bring civil litigation under the federal RICO provisions for conspiracy to commit health care fraud. If the insurer wins a verdict, the individual or the company can be assessed treble damages (three times the amount of demonstrated loss). The possibility of adverse action by state professional licensing authorities exists if a licensed professional, such as a doctor, is found to have engaged in fraudulent billing to insurance companies.
Because the burden of proof is lower in civil litigation, it is critical to have experienced insurance fraud defense attorneys in your corner when accused of these charges.
Whether you are facing single counts of fraud or possible RICO conspiracies, contact the Law Offices of Horwitz & Citro, P.A., immediately. Our early involvement in the audit or criminal investigation may make all the difference. Call (407) 901-5852 or contact us online.
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