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Healthcare Fraud and Abuse

If you or someone you love is being investigated for healthcare fraud or has already been charged, you need a lawyer who understands the industry protocols, statutes and complex nuances of Medicare and Medicaid regulations, and can successfully prepare a defense strategy.

Medicare fraud defense in Texas

Because healthcare fraud and abuse costs U.S. taxpayers billions of dollars each year, the government allocates enormous resources to prosecute those who violate state and federal laws. Unlike many white-collar crimes, healthcare fraud offenses frequently involve statutes specific to the Medicaid and Medicare system.

 

Criminal defense lawyer Jeffery King represents healthcare providers and organizations that are facing charges of Medicaid fraud and abuse, including:

  • Physicians/surgeons
  • Dentists
  • Therapists
  • Nurses
  • Hospitals
  • Equipment providers
  • Assisted Living Care Facilities
  • Laboratories
  • Rehab facilities
  • In-home health care providers
  • Clinics
  • Healthcare marketing companies
  • Pharmacies
  • Medical billings claims companies
  • Private practice owners

What constitutes healthcare fraud?

The term “healthcare fraud” encompasses many different crimes pertaining to the submission of false claims for reimbursement from Medicare, Medicaid or private insurance companies. Medical providers or organizations that bill for services that were not rendered, accept kickbacks to solicit business, or bill for incorrect services or procedures that were not medically necessary may be prosecuted for Medicare fraud.

 

If found guilty of healthcare fraud, sanctions may include:

  • Civil fines for each false claim
  • Loss of licensure and employment
  • Exclusion from Medicare and Medicaid programs
  • Criminal indictment
  • Treble damages
  • Up to 10 years in a federal penitentiary

Medicare & Medicaid fraud

Charges of Medicare/Medicaid fraud often involve allegations of prescribing or performing services that are not medically necessary or submitting false claims for patients who do not exist.

 

Other common allegations of healthcare fraud include:

  • Double billing for services
  • Submitting fraudulent claims to the CMS
  • Billing for equipment or services that are not furnished
  • Up-coding – billing for a more expensive service than the one provided
  • Substituting brand name medications for generic ones
  • Unbundling – billing for tests or treatment separately instead of using the ICD-10 procedure code

Healthcare fraud and abuse laws

Fraud, waste and abuse pose massive liabilities for federal health care programs. As such, there are federal and state statutes designed to deter and punish healthcare professionals who attempt to exploit the Medicare and Medicaid system.

 

Federal laws aimed at identifying and prosecuting healthcare fraud include:

  • The Health Care Fraud Statute – makes it a criminal offense to knowingly execute a scheme to defraud a health care benefit program.
  • The Anti-Kickback Statute – part of the Social Security Act, this statute prohibits the knowing and willful payment, solicitation, or receipt of any remuneration – in cash or gifts – to induce or “in return for referring an individual for the furnishing or arranging for the furnishing of any item or service for which payment may be made under a Federal health care program”
  • The Stark Law – prohibits healthcare providers from referring Medicare and Medicaid patients for specific health services to entities with which they have a financial relationship.
  • The False Claims Act – establishes civil liability for knowingly presenting a fraudulent claim to the government for payment, and making false statements relevant to the fraudulent claim.
  • The Patient Access and Medicare Protection Act – imposes criminal penalties – up to 10 years in jail and monetary fines – for illegally purchasing or distributing Medicaid, Medicare or Children’s Health Insurance Program (CHIP) beneficiary identification or billing privileges.
  • The Civil Monetary Penalties Law – imposes civil penalties on providers who submit false claims, provide false or misleading information in regard to patient discharge, violate Medicare assignment provisions, or fail to provide proper medical screening tests in emergency conditions.

 

Texas is one of several states with aggressive Medicare fraud, waste and abuse laws and anti-kickback statutes, including the Medicaid Fraud Prevention Act passed in 1995. Physicians, therapists, testing laboratories and other medical providers that are accused of healthcare fraud may be held liable for civil and criminal penalties under state and federal statutes.

 

The Department of Justice has two Medicare Fraud Strike Force teams in Texas, which are equipped to bring prosecutions against suspected perpetrators. A Medicaid fraud investigation, even when wholly unfounded, can tarnish the reputation and future growth of private practices and healthcare organizations.

Texas healthcare fraud defense attorney

Dallas criminal defense attorney Jeffery King advocates for clients facing state or federal charges of healthcare abuse throughout the state of Texas, and has the expertise to determine the right defense. For a confidential, no-charge consultation, we invite you to call today.

Additional healthcare fraud and abuse resources:

  1. U.S. Department of Justice, Medicare Fraud Strike Force Charges 91 Individuals for Approximately $430 Million in False Billing https://www.justice.gov/opa/pr/medicare-fraud-strike-force-charges-91-individuals-approximately-430-million-false-billing
  2. Centers for Medicare & Medicaid, Common Types of Health Care Fraud https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-factsheet.pdf
  3. FBI, Health Care Fraud https://www.fbi.gov/investigate/white-collar-crime/health-care-fraud
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JEFFERY KING, PLLC.
2626 Cole Ave.
Suite 415
Dallas, Texas 75204
T: 469-399-7001
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