What Is Health Care Fraud?

Unlike other health law matters, health care fraud cases progress very quickly and carry significant penalties and fines. In recent years the federal government has teamed up with state and local government to aggressively identify and stop health care fraud. Investigators are often ruthless and use informants, previous employees and others with potential inside information to assist in the investigation and prosecution.

As a result, incidental errors or negligence are often identified as potential fraud. With significant increases in funding from the federal government for health care fraud audits, health professionals are often faced with intrusive investigations. If you are under investigation, it is important to be prepared as early as possible.

Examples of Health Care Fraud

If you have been arrested for health care fraud, contacted by federal or state/local law enforcement, or contacted by a medical insurer raising questions of potential fraud, you face serious penalties. If you’re unsure of what health care fraud looks like, below are a few examples:

• Kickbacks
• Submitting false claims to CMS for payment
• Billing for ghost patients, services not provided, equipment not provided, or low-quality services
• Overutilization of certain medical procedures or services
• Lack of medical necessity
• Making false statements on applications or contracts
• Providing false or misleading information expected to influence a decision to discharge a patient

Penalties

If you are convicted of health care fraud, below are some of the potential consequences you face:

• Healthcare Fraud: Up to 10 years in prison and up to 20 years if there is bodily injury
• Conspiracy to Commit Healthcare Fraud and Fraud: Up to 20 years
• False Claims Act Convictions: Up to 5 years per occurrence and up to life if convicted of multiple counts
• Money Laundering: Up to 10 years
• Conspiracy to Commit Money Laundering: Up to 20 years
• Wire Fraud: Up to 20 years

You also face up to $250,000 in fines, depending on the severity of the crime. Other sanctions include loss of licensure, loss of DEA registration, exclusion from Medicare and Medicaid, suspension of payment on outstanding invoices and loss of staff privileges.