An individual, group of individuals or a company commits federal health care fraud by knowingly making a misrepresentation or misstatement involving the type, extent or nature of the treatment or services that is being provided. This misrepresentation must be made in a way that could lead unauthorized payments.
This offense involves billing for services that were not delivered or goods that were not provided. Examples include falsifying medical necessity certificates and billing for services that were not medically necessary, filing individually for services that should be included in a single fee, falsifying medical records or treatment plans to support payments, misrepresenting diagnosis or procedures to maximize payments, misrepresenting charges or payment entitlements in cost reports and seeking kickbacks for services or goods that were provided.
Health care fraud may be committed against health insurers and companies including Medicare, Medicaid, Blue Cross/Blue Shield, and workers’ compensation. It may involve Part A Medicare Services including hospital care, home health care and skilled nursing care along with Part B coverage involving physician services, laboratory tests, x-rays, outpatient services and medical supplies.
Several federal law enforcement agencies investigate this crime, sometimes in conjunction with state authorities. Court may sentence impose imprisonment, criminal fines, and victim restitution as part of criminal sentencing. Health professionals and institutions may also face prosecution.
Additionally, civil prosecutions may be filed for monetary damages. Their amounts can double or triple if there were false or fraudulent claims. Courts can also prevent the defendants from take part in the identified conduct and temporary suspensions or debarments from Medicare and related programs.
If you are under investigation for health care fraud or other white-collar crime, you should immediately seek legal representation. An attorney can help protect your rights.