What is healthcare fraud? The term “fraud” refers to any dishonest and deliberate act committed with full knowledge that the result could be an unauthorized, inappropriate benefit to someone who is not entitled to receive that benefit.
Federal healthcare laws govern how the healthcare system works. Per the U.S. Federal Bureau of Investigation (FBI), healthcare fraud results in the following:
- The loss of tens of billions of dollars every year
- Unnecessary medical procedures, impacting patient safety
- Increased health insurance costs
- Increased taxes
If you’ve been charged with federal healthcare crimes, the Zoukis Consulting Group can help. Call us today to speak to a healthcare fraud lawyer about how we can defend your rights in court.
Who Commits Healthcare Fraud?
Medical providers, patients, and anyone else who purposefully deceives the healthcare system to receive payments or benefits they are not entitled to are committing healthcare fraud.
What Types of Fraud are Committed by Medical Providers?
- Billing for services and items that were not provided (called “phantom billing”)
- Billing for services and items that are not medically necessary
- Billing or services that were not properly documented
- Misrepresentation of the level or type of service provided
- Misrepresentation of the person who provided the service
- Seeking reimbursement or payment for procedures that are essential to others conducted on the same date (called “unbundling”)—that is, double billing, submitting multiple bills for the same service
- Seeking increased reimbursement or payment for services that are properly billed at a lower cost (called “up-coding”)
What Types of Fraud are Committed by Patients or Others?
- Impersonating a healthcare provider through rendering services or billing for healthcare services or equipment without a license
- Engaging in false marketing by convincing individuals to provide their health insurance identification numbers or other personal information to steal their identities, bill for unrendered services, or enroll them in a bogus benefit plan
- Committing identity theft either by using another individual’s health insurance or improperly allowing someone who is not covered to use your insurance information
What is Prescription Medicine Fraud?
Prescription medicine fraud is a type of healthcare fraud that is specific to behavior regarding prescription medications, such as the following:
- Using or creating forged prescriptions
- Visiting multiple healthcare providers to obtain several prescriptions for controlled substances, such as opioids
- Obtaining prescriptions from a provider or medical office that practices unethical behaviors
Who Investigates Healthcare Fraud?
The FBI is the primary agency responsible for investigating federal healthcare fraud for government and private health insurance programs. The agency partners with federal, state, and local agencies.
Agencies that investigate healthcare fraud include Medicare’s Healthcare Fraud Prevention Partnership (HFPP). The HFPP “fosters a proactive approach to combating healthcare fraud, waste, and abuse.”
Insurance groups also investigate healthcare fraud. These groups include the National Insurance Crime Bureau, the National Health Care Anti-Fraud Association, and health insurance company investigative units.
If you are being investigated by the FBI, consult with a healthcare fraud lawyer to protect your rights.
What Steps can Healthcare Providers and Staff Take to Help Prevent Healthcare Fraud?
There are multiple steps that medical providers and staff can take to help prevent healthcare fraud, including:
- Always ensure accuracy when submitting claims or bills for services or items provided.
- Never provide medically unnecessary procedures, treatments, or drug prescriptions.
- Confirm all member ID cards and ask to see patients’ drivers’ licenses or other appropriate photo IDs to ensure accuracy.
- Report stolen or lost prescription pads.
- Report fraudulent prescriptions.
What can Patients and Others do to Help Prevent Healthcare Fraud?
Always protect your healthcare information. Remember that your personal information is protected under HIPAA, the Health Insurance Privacy and Accountability Act, by the Federal Privacy Rule.
HIPAA provides you with specific rights regarding your health information. It also sets limits on who has access to your health information. The privacy rule applies to all types of a person’s protected health information (PHI), including electronic, written, or oral.
Therefore, treat your health insurance and medical information like your credit card or social security number (the latter of which is considered PHI). Be careful when providing this information at your doctor’s office or pharmacy, and do not share it with others.
Always review the explanation of benefits (EOB) you receive from your health insurance policy. Ensure that the locations, dates, and services on the EOB match the specific services you received and when and where they were provided.
Be skeptical of any so-called free services. If asked to provide your health insurance information to receive free services, they are probably not free or legitimate and may result in fraudulent charges billed to your insurance company.
Defense for Healthcare Fraud Charges
When someone is convicted on federal health care fraud charges, the consequences can be significant. It is important to engage knowledgeable medical fraud lawyers who will defend and protect your rights. Depending on the facts and circumstances surrounding the charges, there are several potential defenses healthcare fraud attorneys may assert.
If the charges relate to billing fraud, a skilled medical billing fraud lawyer may be able to prove that the errors were nothing more than simple mistakes and that the defendant had no malicious intent to defraud anyone.
Sometimes, a valid defense strategy is to show that the prosecution lacks the evidence needed to prove that the defendant is guilty beyond a reasonable doubt. The burden of proof rests with the prosecution, so if there is insufficient evidence, it is unlikely that a jury could find the defendant guilty.
While federal agencies may conduct lengthy and seemingly thorough investigations into alleged health care fraud, obtaining documents they believe are evidence of fraud, talking to former employees or other potential witnesses, and even seizing the defendant’s assets, these measures do not always yield sufficient evidence for the prosecution to meet its burden of proof. In that case, the charges may be dropped entirely.
Call Us If You’re Charged with Federal Healthcare Fraud
If you’ve been charged with federal healthcare fraud, contact the federal health care fraud lawyers at Zoukis Consulting Group. We will go to court for you to ensure your rights are upheld. We can also work to get you a lesser sentence.
Contact the Zoukis Consulting Group now to schedule an initial consultation with a medical fraud defense attorney.
Published Feb 15, 2022 by Christopher Zoukis, JD, MBA | Last Updated by Christopher Zoukis, JD, MBA on May 12, 2023 at 1:22 pm