Have you been notified of an insurance audit or been accused of Healthcare fraud? At Oakley & Oakley, LLC, an experienced Lexington healthcare fraud lawyer can help you defend your rights and future. Contact us today at (859) 254-4035 to schedule a free case review.
If you are a healthcare provider, a conviction for healthcare fraud can prevent you from using your license permanently. This is a serious offense, and a conviction can result in severe penalties, including lengthy imprisonment and substantial fines.
We pride ourselves on finding solutions to our clients’ problems. When we are representing healthcare providers, we will do everything possible to keep your license intact and untouched. We offer a free consultation to discuss your case and explain your legal rights and options.
Why You Need to Call Oakley & Oakley, LLC Can Help If You Are Facing Healthcare Fraud Charges in Lexington, Kentucky
Healthcare fraud defense is highly specific, and many criminal defense lawyers do not regularly work in this area. Because they don’t understand the area of law, they may encourage clients to accept a plea, when in fact they are not guilty. Choosing a lawyer to represent you who understands the legal charges is not only important, it is necessary.
When you hire a federal crimes attorney at Oakley & Oakley, LLC, we understand that everything is at stake, and will take your legal matter seriously. Our Lexington criminal defense attorneys will explore every available avenue to get your case dismissed, evidence excluded or suppressed, or negotiate reduced charges. We will also prepare your case for trial, so that we can argue your case in front of a judge or jury.
Our lawyers represent all types of licensed medical professionals, including:
- Mental health professionals/therapists
- Nurses and nurse practitioners
- Pain management specialists
- Other licensed health care professionals.
Federal investigations are complex matters, especially when multiple agencies are involved. When you hire us, we will work with experts including former FBI agents, private investigators, medical billing and coding experts, medical experts, and compliance officers to establish proof that either medical services were necessary or that fraud was not committed.
Our law firm represents clients across Lexington and throughout Fayette County – call us to get started with a free health care fraud defense evaluation today.
What is Healthcare Fraud?
According to the National Conference of State Legislatures, healthcare fraud costs insurers between $70 billion and $234 billion every year. Getting accurate figures is impossible, because not all fraud is discovered, and not all claims turn out to be fraudulent. However, any allegations of healthcare fraud are taken very seriously.
Agencies can take many different types of actions against healthcare practices, all with significant penalties and consequences, even being required to be paid the government’s legal fees.
In the United States, there are four laws most commonly used to charge people with healthcare fraud:
- Criminal Healthcare Fraud Statute:18 U.S.C. §1347 and §1349 – healthcare Fraud and Conspiracy to Commit healthcare Fraud – these statutes make it illegal for medical care providers to defraud or knowingly make false claims against a healthcare benefit program
- The False Claims Act: This is an act designed to help taxpayers recover money that has been stolen from the federal government, and is often used to guard against fraudulent Medicare claims. In 2015 alone, the Justice Department recovered $3.5 billion in settlements and judgments under the False Claims Act, including $1.9 billion from companies and individuals in the healthcare industry (federal losses alone).
- The Stark Law: The Stark Law (Stark Amendment to Omnibus Budget Reconciliation Act of 1989) is a law that applies to physician referrals to entities in which they have a financial interest.
- Anti-Kickback Statutes: 42 U.S.C. § 1320a-7b(b) makes it illegal for physicians and other healthcare providers to swap goods or services for business opportunities under insurance providers. This type of “cash for patients” fraud can occur even if patients need service and the care they receive is of good quality.
It is possible that you could be charged with other white-collar crime charges, and healthcare fraud charges brought later. If you work closely with other healthcare providers and they have been charged with any healthcare fraud, you may benefit from speaking to legal counsel.
How Do I Know If I’m Being Investigated for Healthcare Fraud?
Healthcare fraud investigations can take different shapes. Sometimes an indictment may be unsealed simultaneously with the execution of a search warrant, and you will have no notice.
If you receive any of the following, you need counsel immediately:
- Increased audits and record requests by Medicare, Medicaid, and commercial insurance companies
- Suspension from Medicare based on allegations of fraud (credible or suspected)
- Civil Investigative Demand
- Search warrant
- Grand Jury Target letter
- Grand Jury Subject letter
- Grand Jury Subpoena
- Grand Jury Witness Letter (witnesses often turn into subjects without legal counsel).
The FBI is the primary agency for investigating and exposing healthcare fraud.
The agency may form “investigative partnerships” with other agencies, including:
- Health and Human Services-Office of Inspector General (HHS-OIG)
- Food and Drug Administration (FDA)
- Drug Enforcement Administration (DEA)
- Defense Criminal Investigative Service (DCIS)
- Office of Personnel Management-Office of Inspector General (OPM-OIG)
- Internal Revenue Service-Criminal Investigation (IRS-CI).
- Local law enforcement agencies.
If you receive notice of investigation in a civil action or administrative action, you should also prepare for a criminal investigation. The sooner you have representation, the sooner they can begin taking steps to protect you. If your office is raided, your phone and computer may be taken away and you may feel you have no choice but to talk to investigators. Always remain calm and remember, agents cannot force people to be interrogated.
What Does the Prosecution Have to Prove to Get a Healthcare Fraud Conviction?
If you are charged with healthcare fraud, the prosecution will focus on proving three things:
1. Fraudulent Intent
To be successful in a conviction, federal prosecutors must establish that you intended to “knowingly and willfully execute” a scheme or artifice to defraud any healthcare benefit program.
2. Fraudulent Activity or Attempts
If the prosecutor cannot prove that fraud was actually committed, they may instead try to prove that fraud was attempted. The U.S. healthcare fraud statute does not distinguish between actually committing fraud and attempting to commit it.
3. Target of Fraud was a Healthcare Benefit Program
The target of a scheme must be a government or private healthcare benefit or insurance company, organization, etc.
Healthcare fraud can refer to a wide variety of conduct designed to obtain a financial benefit to the detriment of a health insurance or government entity. In some cases, patients are harmed, in other cases, they are not.
Common healthcare fraud schemes include:
- Billing for medical services that were not performed. The term “ghost patients” may be used to refer to patients who do not exist or who never received the billed service.
- Falsifying a diagnosis to justify diagnostic tests, procedures, or surgeries that are medically unnecessary. In other words, performing and submitting claims for services when there is a lack of medical necessity.
- Unbundling, a form of billing multi-step procedures separately, instead of as one single procedure.
- Billing for more costly service than is actually performed.
- Waiving co-pays or deductibles and overbilling the insurance carrier
- Misrepresenting procedures performed to cover non-covered surgeries.
Medicare, Medicaid, Tricare, and health insurance companies like UnitedHealthcare, Anthem, Aetna, Cigna Health, and Humana, all work with state and federal law enforcement to prevent, detect, and prosecute cases of healthcare fraud. If you know you are being investigated for healthcare or Medicare fraud, do not wait until you are charged.
Telemedicine and Telehealth Fraud
The COVID-19 pandemic has changed healthcare. Following the coronavirus pandemic, telemedicine is on the rise. Doctors are billing the same rates to talk to patients on Zoom and Skype, and patients could receive prescriptions from doctors without having to leave their homes.
The use of phone or video appointments protects patients and doctors is convenient, but have created new priorities for abuse and fraud. If you are accused of healthcare fraud related to care during the COVID-19 pandemic, do not delay in contacting a Lexington healthcare fraud defense lawyer.
What Are the Penalties For Healthcare Fraud Convictions in Kentucky?
Penalties for healthcare fraud can be criminal, civil, and administrative. Strategies for healthcare fraud defenses should never be based on potential jail time alone. Having a lawyer who understands the extent of what is at stake is critical to obtaining the best outcome.
Potential penalties for healthcare fraud include:
- Up to 10 years in federal prison
- Fines of up to $250,000 per offense
- Forfeiture of assets related to the alleged offense
- Loss of board certification status
- Loss of employment
- Loss of professional license (medical license, nursing license, pharmacy license, etc.)
- Mandatory exclusion from billing Medicare and Medicaid for between five years to life
- Pre-payment checks for future claims
- Restitution to victims.
People charged with healthcare fraud often face multiple criminal charges which can exponentially increase penalties.
Along with healthcare fraud, they may be charged with:
- 18 U.S.C. 1343 — Wire Fraud
- 18 U.S.C. 1344 — Bank Fraud
- 18 U.S.C. 2320 — Counterfeiting
- 18 U.S.C. 1961 — Racketeering
- 18 U.S.C. 1956 — Money Laundering
- 21 U.S.C. 841(a) – Drug Trafficking
- 42 U.S.C. 1320a-7b — Anti-Kickback Statute
- 18 U.S.C. 371 — Conspiracy
Of course, every situation is unique and different. You should not assume that because someone wasn’t charged, that you won’t be charged either. If you know that you are under investigation for any type of white collar crime, contact the lawyers at
What Defenses Can Be Used to Fight Healthcare Fraud Charges in Lexington, KY?
Healthcare fraud is a type of “white-collar crime.” There are a number of defenses available to someone charged with healthcare fraud.
- Mistake: Intent is an element of a healthcare fraud crime. If the claims were submitted mistakenly or erroneously, the act cannot be considered fraud. Innocent errors are often referred to as a “good faith defense.” This defense may not work in every situation.
- Someone Else Committed the Fraud: Billing tasks are often divided up and it can be unclear who was working on legitimate tasks, and who was acting fraudulently. For example, if a second employee submits information to insurance companies, they may be just completing assigned tasks and have no knowledge of the allegedly fraudulent activity.
- Constitutional Violations: Government agencies and the police have to abide by certain rules when investigating allegations of healthcare fraud. If your right shave been violated – perhaps through an unlawful arrest or illegal search and seizure – it’s important to raise those issues with the court. It could lead to getting evidence suppressed or having a judge toss the charges against you, entirely.
If you are investigated or charged with healthcare fraud, you are up against prosecutors with endless resources and a complex system. This can be an incredibly stressful and uncertain time. Do not risk your future by hiring an unqualified lawyer to represent you.
Get a Free Consultation With A Lexington Healthcare Fraud Lawyer at Oakley & Oakley, LLC
At Oakley & Oakley, LLC, our Lexington healthcare fraud lawyers have more than 15 years of experience handling white-collar crimes like healthcare fraud. Having handled many cases involving fraud, we understand how much is at stake. Call our law offices today to discuss your case with one of our experienced attorneys. Your initial consultation is free.