Federal Healthcare Fraud

Healthcare fraud, a type of white collar crime, is a complex and pervasive issue in the United States, costing the government billions of dollars annually.  Federal laws and regulations are in place to combat these fraudulent schemes, which can take various forms.  Because of the significant amount of money that is generally involved in healthcare fraud schemes, they are almost always charged as felonies.

Several federal statutes address healthcare fraud in the United States.  However, the most prominent federal statute that criminalizes healthcare fraud is the Anti-Kickback Statute.  The Anti-Kickback Statute, which is contained in sections 1320a-7b of Title 42 of the United States Code, makes it illegal to knowingly offer, pay, solicit, or receive remuneration in exchange for referrals or services reimbursed under federal healthcare programs.  Violations of the Anti-Kickback Statute can result in criminal charges, civil monetary penalties, and exclusion from federal healthcare programs.

Healthcare fraud schemes come in various forms, often exploiting the complexity of the healthcare system.

Billing for Unnecessary Services: Providers may bill for medical services or procedures that patients did not need or receive.  This can involve anything from diagnostic tests to surgical procedures.

Upcoding and Unbundling: Providers might use fraudulent codes to bill for more expensive services or unbundle services that should be billed together, increasing reimbursement amounts.

Kickbacks and Referral Schemes: Healthcare professionals, such as doctors, may accept kickbacks or other incentives in exchange for referring patients or ordering specific medical tests or treatments.

Phantom Patients: Some schemes involve creating fake patients or inflating the number of patients seen to generate additional claims for services that were never provided.

Identity Theft: Fraudsters may steal patients’ personal information to submit false claims for medical services or prescription drugs under their names.

Defending clients facing healthcare fraud charges is a complex undertaking.  There are several defenses that may be employed in order to defend a client who is accused of participating in a healthcare fraud scheme.

Lack of Intent: Many healthcare fraud statutes require a specific intent to defraud the government or healthcare programs.  Demonstrating that the defendant lacked the requisite intent can be a powerful defense strategy.

Insufficient Evidence: Attack the government’s case by challenging the evidence presented.  This might include arguing that the government failed to prove the elements of the alleged offense beyond a reasonable doubt and therefore making a motion to dismiss.

Statute of Limitations: Healthcare fraud cases must be brought within a specified timeframe.  If the government misses the statute of limitations, it can serve as a basis for dismissal.

Compliance with Regulations: Show that the healthcare provider had robust compliance programs in place and acted in good faith to ensure compliance with healthcare regulations.

Whistleblower Motivation: If a whistleblower initiated the case, investigate the whistleblower’s motivations and credibility to challenge the legitimacy of their claims.

Overzealous Prosecution: Argue that the government is overreaching or engaging in prosecutorial misconduct in its pursuit of the case.

Negotiating a Plea Deal: In some cases, it may be in the defendant’s best interest to negotiate a plea deal that results in reduced charges or more lenient sentencing.  This could be achieved by a proffer agreement, if the charges allege multiple defendants were involved in the scheme, or may involve some type of immunity against prosecution in exchange for the defendant’s testimony against others.

Navigating healthcare fraud cases requires a combination of legal expertise, thorough case analysis, and strategic advocacy.  If you are facing charges for engaging in a healthcare fraud scheme, it is absolutely critical that you discuss your case with an experienced criminal defense attorney.  As a former Deputy District Attorney with over 14 years of prosecutorial experience, Los Angeles criminal defense attorney Michael Kraut has extensive experience in federal court with a track record of favorable results for his clients, many of whom avoid custody time altogether.

For more information about the criminal justice process, and to schedule your free consultation, contact Michael Kraut at the Kraut Law Group located at 6255 Sunset Boulevard, Suite 1520, Los Angeles, CA 90028.  Mr. Kraut can be reached 24/7 at (888) 334-6344 or (323) 464-6453.