Healthcare fraud is among the biggest threats faced by the healthcare service industry. It’s estimated that it costs the U.S. government and the American people more than $100 billion annually. Federal and state agencies are very serious about combating healthcare fraud and investigations and prosecutions have become much more aggressive in recent years.

Since many cases of fraud occur with the involvement of healthcare service providers, any suspicious activity on your part can bring you under scrutiny of law enforcement agencies. Forget about a conviction. Even an investigation can ruin you professionally and financially. In such a situation, only a skilled and experienced healthcare enforcement action defense lawyer can help you clear your name.

Examples of the types of healthcare fraud:

  • Billing for services not provided: This involves billing Medicare for a service the patient did not receive. This is usually done by forging the signature of a patient and giving kickbacks to corrupt Medicare officials.
  • Upcoding of lower-cost services: This involves billing Medicare for services that are costlier than the procedures that were performed.
  • Upcoding of lower-cost items: This involves billing Medicare for items that are costlier than those that were used or provided to the patient.
  • Making duplicate claims: This involves changing some portions of a bill (such as the date) that was already submitted to Medicare and submitting it again to be paid twice for the same service provided.
  • Unbundling of bills: Healthcare services normally cost less when they are bundled together. But, a clever healthcare service provider can get a higher payout by manipulating the claims and staggering the bills over time.
  • Billing for excessive services: This involves billing Medicare for services and equipment that were of a higher level than was required.
  • Billing for unnecessary services: This involves billing Medicare for services that don’t apply to the patients’ condition, such as an MRI for a patient with a sprained wrist.
  • Violating the Stark Law: The Stark Law, also known as Physician Self-Referral Law, prohibits physicians from referring their patients to DHS providers in which they (or their direct family members) have direct or indirect ownership, investment interest or compensation arrangements. Violating the Stark Law is punishable by denial of Medicare to the designated health service, as well as a fine of up to $100,000.
  • Receiving kickbacks: The anti-kickback statute prohibits physicians from receiving any form of compensation when making referrals or purchasing medical equipment, facilities, services or any other items covered by Medicare or Medicaid. Violation of the anti-kickback statute is punishable by a fine of up to $25,000 and a five-year prison term.

healthcare fraud recovery - Healthcare Enforcement ActionsHealthcare Fraud Recovery

Healthcare fraud recoveries eclipsed $2 billion for the second year in a row and represented fraud schemes committed by drug companies, hospitals, pharmacies, health IT vendors, laboratories, and physicians, said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.

Source: HealthPayer Intelligence

Government Agencies Involved in Healthcare Enforcement Action

Both the federal and state governments have agencies that are involved in enforcing laws and rules to discourage healthcare fraud. The federal government has the Department of Justice (DOJ), Federal Bureau of Investigation (FBI), Drug Enforcement Administration (DEA), Office of Investigations for the Office of Inspector General for the Department of Health and Human Services (DHHS), and the Office of Criminal Investigations of the Food and Drug Administration (FDA). You could be investigated by any of them.

Healthcare fraud is a serious crime with severe penalties for the offender. Sometimes, violations can occur without your knowledge, such as a billing error. It’s best to put systems in place to audit your organization to find errors before they cause serious problems. If a violation is discovered, either through a routine audit or an investigation, it’s wise to contact a healthcare enforcement action attorney.