Health Care Fraud

Health care fraud cases are often complex, requiring a deep understanding of both federal and state laws. These cases involve allegations of intentionally deceiving health care programs, such as Medicare, Medicaid, and private insurers, to receive unauthorized payments. Health care fraud is prosecuted aggressively by the government, and those accused often face severe criminal, civil, and administrative penalties that can be addressed by federal criminal defense attorney Nate Crowley.

Types of Health Care Fraud Offenses

There are many different types of health care fraud.

1. Fraudulent Billing
   • Upcoding: Charging for a more expensive procedure than what was actually provided.
   • Phantom Billing: Billing for services, procedures, or equipment never provided.
   • Unbundling: Separating services that should be billed together to increase reimbursement.
2. Illegal Kickbacks
   • Violating the Anti-Kickback Statute by offering or receiving payments for patient referrals or services paid by federal health care programs.
3. Prescription Drug Fraud
   • Pill Mill Schemes: Accusations of prescribing unnecessary medication, often opioids, in exchange for financial gain.
   • Drug Diversion: Selling prescribed drugs on the black market or submitting false claims for reimbursement of medications.
4. False Claims
   • Violations of the False Claims Act, which involve submitting fraudulent claims to Medicare, Medicaid, or other federal programs.
5. Self-Referral Violations
   • Violating the Stark Law, which prohibits physicians from referring patients to entities in which they have a financial interest.

Potential Penalties for Health Care Fraud

Criminal penalties for health care fraud include:

• Up to 10 years imprisonment per offense.
• Up to 20 years imprisonment if the fraud results in serious bodily injury.
• Life imprisonment if the fraud results in a patient’s death.
• Fines up to $250,000 for individuals and $500,000 for organizations.

Civil penalties for health care fraud include:

• Treble (triple) damages under the False Claims Act.
• Civil fines ranging from $11,000 to $23,000 per false claim.

Administrative penalties for health care fraud include:

• Exclusion from participating in Medicare, Medicaid, and other federal health programs.
• License suspension or revocation for medical professionals.

Possible Defenses in Health Care Fraud Cases

Approaches that may be taken for defending a charge of health care fraud include:

• Lack of Intent: Many health care fraud charges require proof of intent to defraud. Demonstrating that the accused acted without fraudulent intent can be a strong defense.
• Clerical Errors: Mistakes in billing or documentation without criminal intent may serve as a defense if supported by proper records.
• Good Faith: A defense may involve showing that the accused acted in good faith, relying on expert advice or interpretations of complex billing rules.
• Insufficient Evidence: Challenging the evidence presented by the prosecution, such as questioning the accuracy of audits or whistleblower testimony.
• Duress or Coercion: In some cases, defendants may argue that they were pressured or coerced into fraudulent actions by supervisors or business partners.

Health Care Fraud Offenses in California

In California, health care fraud is prosecuted under both federal statutes and state laws such as Penal Code §550, which criminalizes fraudulent health insurance claims. The state also enforces the California Insurance Frauds Prevention Act and Medi-Cal fraud statutes.

Penalties for health care fraud in California can include imprisonment of up to 5 years per count, significant fines, restitution, and loss of professional licenses. A strong defense often involves demonstrating lack of intent, reliance on expert advice, or procedural errors by insurers or regulators. Early intervention and negotiation by federal criminal defense attorney Nate Crowley with prosecutors are key in achieving favorable outcomes.

Charged With Health Card Fraud? Contact Federal Criminal Defense Attorney Nate Crowley

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