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Healthcare Fraud in Criminal Fraud

In recent years, health care fraud has become a huge priority for the federal government and has led to many federal criminal charges by the U.S. Department of Justice (DOJ) and investigations by the Office of Inspector General (OIG).

The DOJ recently announced the filing of federal criminal charges against more than 600 defendants nationwide accused of committing health care fraud in excess of two billion dollars. If you have come under investigation for or been accused of federal health care fraud, you could seek assistance from a Jefferson County healthcare fraud lawyer. An aggressive fraud defense attorney could be essential for combatting any charges that result and clearing your name.

Defining Healthcare Fraud

When a healthcare provider or a consumer intentionally submits false or misleading information about the value of the healthcare benefit that should be paid by an insurance or health care benefit program, they commit health care fraud under federal law.

Some common types of conduct by medical providers that could constitute federal health care fraud may include the following:

  • Billing for medical services that were not provided
  • Providing inaccurate medical information to justify the costs of unnecessary tests and procedures
  • Misrepresenting the nature of ineligible medical procedures so that the insurance program will cover them
  • Billing for more expensive services than those that were provided
  • Accepting funds in exchange for patient referrals

Consumers also may commit federal healthcare fraud in various ways, such as filing false claims for medical services or medications that they did not receive, altering bills or receipts to increase their claim amounts, and using others’ insurance cards or coverage to benefit themselves in some way. A Jefferson County healthcare fraud lawyer could explain to a person on what grounds they were charged with health care fraud.

Federal Law and Healthcare Fraud

The federal crime of healthcare fraud is found at 18 U.S. Code § 1347. That statute provides that individuals commit health care fraud if they intentionally execute or attempt to execute a plan to defraud any healthcare benefit program or obtain money or property belonging to any healthcare benefit program through false or fraudulent pretenses or representations.

Individuals are not required to have actual knowledge or specific intent to commit a violation of this crime. Given the wide scope of this federal criminal offense, consulting with an experienced attorney may be helpful.

There also are specific federal criminal fraud laws that relate to Medicaid and Medicare, which are federal public health care insurers. It is a crime under 18 U.S. Code § 287 to make false, fictitious, or fraudulent claims against the United States and any of its agencies. 18 U.S. Code §1001 prohibits making any materially false statements or fraudulent documents in matters within the jurisdiction of any branch of the U.S. government.

Possible Penalties a Defendant May Face

Under federal law, individuals may face up to ten years in prison, as well as a substantial fine. If the offense results in serious bodily injury to another, the potential prison sentence increases to 20 years, and if the offense results in death to another, the potential sentence rises to life in prison.

Making false statements with respect to Medicaid or Medicare claims could result in a federal prison sentence of up to five years, a fine of up to $250,000 ($500,000 for organizations) or both.

In federal fraud cases, judges also may order individuals to pay restitution for their crimes, in addition to the fines paid to the government. Individuals who are convicted of health care fraud may have to pay back the total value of the funds that they received as a result of their fraud.

Health care providers who commit fraud involving Medicaid or Medicare may no longer be able to bill any federal health care program, which could mean that practicing medicine will no longer be a financially viable option.

A healthcare fraud lawyer in Jefferson County could explain what an accused person’s legal options when facing healthcare fraud allegations.

How a Jefferson County Healthcare Fraud Attorney Could Help

Whether you are a consumer or a healthcare provider accused of fraudulent behavior in connection to healthcare billing and claims, you should take action as soon as you become aware that the DOJ or OIG has started investigating you. A Jefferson County healthcare fraud lawyer could be instrumental in avoiding federal criminal charges and the penalties that can result from a conviction.

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