Lexington Health Care Fraud Lawyer

What Does The Prosecution Have To Prove To Get A Health Care Fraud Conviction?

If you are charged with health care 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 a health care 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. health care fraud statute does not distinguish between actually committing fraud and attempting to commit it.

3. Target Of Fraud Was A Health Care Benefit Program

The target of a scheme must be a government or private health care benefit or insurance company, organization, etc. Health care 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 health care 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 multistep 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 health care fraud. If you know that you are being investigated for health care or Medicare fraud, do not wait until you are charged.

Telemedicine And Telehealth Fraud

The COVID-19 pandemic has changed health care. 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 can receive prescriptions from doctors without having to leave their homes. The use of phone or video appointments protects patients and doctors and is convenient, but it has also created new priorities for abuse and fraud. If you are accused of health care fraud related to care during the COVID-19 pandemic, do not delay in contacting me.

What Are The Penalties For Health Care Fraud Convictions In Kentucky?

Penalties for health care fraud can be criminal, civil and administrative. Strategies for health care 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 health care 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
• Prepayment checks for future claims
• Restitution to victims

People charged with health care fraud often face multiple criminal charges, which can exponentially increase penalties. Along with health care 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, you won’t be charged, either. If you know that you are under investigation for any type of white collar crime, contact me at Oakley & Oakley, LLC.

What Defenses Can Be Used To Fight Health Care Fraud Charges In Lexington?

Health care fraud is a type of white collar crime. There are a number of defenses available to someone charged with health care fraud. These include:

• Mistake: Intent is an element of a health care 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 without knowledge of the allegedly fraudulent activity.
• Constitutional violations: Government agencies and the police have to abide by certain rules when investigating allegations of health care fraud. If your rights have 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 health care 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 Health Care Fraud Lawyer At Oakley & Oakley, LLC

At Oakley & Oakley, LLC, I have nearly 20 years of experience handling white collar crimes like health care fraud, so I understand how much is at stake. Call my law offices today to discuss your case with me. Your initial consultation is free.