Being a healthcare provider comes with an obligation to know and abide by Medicare’s rules.
Why? Because if you stray from the regulations in place — such as overbilling for services, charging for unprovided or unnecessary services, paying kickbacks for business — your practice will come under fire from federal Medicare fraud prosecutors.
Medicare fraud audits have the potential to evolve into criminal indictments, as well as civil recovery actions and state professional licensing complaints. You will be facing jail time, tens of thousands of dollars in overpayment demands, professional license suspension — even full revocation — and Medicare exclusion.
Our national healthcare fraud lawyers have everything you need to know about Medicare fraud investigations and audits — and why allegations should be taken seriously.
Before learning about Medicare fraud, it is important to understand exactly what healthcare fraud entails. Healthcare fraud is a general term that applies to any scheme to commit fraud (a material misrepresentation designed and intended to result in financial gain) against a health care insurance program.
Healthcare fraud occurs when an individual knowingly submits a false statement or makes misrepresentations of fact, to obtain payment from a Federal health care program (Medicare, Medicaid, TriCare) for which no entitlement would otherwise exist.
When a claim is submitted for reimbursement for services that were either not medically necessary, not conducted, overbilled, or not allowable, the person and entity that caused the bill to be submitted can be prosecuted for fraud.
For Medicare fraud, that encompasses regulatory provisions, including the false claims act, Anti-Kickback Statute (federal and state specific), Stark Laws, and health care fraud statutes.
Individuals who knowingly solicit, pay and/or accept remuneration to induce or reward patient referrals for services or supplies reimbursed by a federal health care program, may also be guilty of Medicare fraud, along with those making prohibited referrals for certain designated health services.
Criminal Medicare fraud convictions require proof beyond a reasonable doubt that an individual knowingly and/or willfully submitted a false claim or engaged in kickbacks or healthcare fraud.
However, proof of actual knowledge or specific intent is not required for a conviction. A person can be convicted if they are found to have acted with deliberate ignorance or reckless disregard of the truth or falsity of the claim.
In some Medicare fraud cases, the ultimate issue is simply whether the individual acted knowingly and/or willfully. In other cases, the issues are much more complex.
For example, Medicare fraud allegations involving worthless services, medical necessity or overutilization present an additional question regarding the standard of care. The current government trend is to criminally charge physicians, pain management specialists, chiropractors, dentists, or other licensed medical professionals who allegedly prescribe/perform health care services that are not medically necessary.
Our team of national Medicare fraud defense lawyers is dedicated to defending providers and suppliers suspected of Medicare fraud. They have significant experience in federal criminal defense, health care fraud investigations, regulatory compliance, audits, and civil and criminal Medicare fraud actions. In fact, our team includes a former Deputy Attorney General for the Medicaid Fraud Control Unit (MFCU) who prosecuted health care fraud cases.
We have built our team of national Medicare fraud defense lawyers to represent individuals across the U.S. who accused of fraud, through offices in Troy, Michigan; and Miami and Sarasota, Florida. Our clients include physicians, chiropractors, pharmacists, home health agencies, urgent care centers and behavioral health facilities.
In addition, we have an extensive network of experts who specialize in nearly every area of medicine — from board-certified pain management doctors to retired DEA drug diversion agents and private investigators — as well billing and coding.
Some of our current and recent Medicare fraud cases include:
Each lawyer in our healthcare defense practice at Chapman Law Group is uniquely suited to defend national Medicare fraud claims, as well as Qui Tam and whistleblower actions. Our knowledge of conditions of payment, conditions of participation, and 35 years of defending physicians accused of malpractice, give us the knowledge to understand and apply the standard of care, DRG’s, CPT’s, clinical practice guidelines and conditions of payment in the defense of our clients.
Our four national health care-based criminal defense law offices are in Detroit, Michigan; Miami and Sarasota, Florida; and Los Angeles/Southern California. We serve healthcare providers across the U.S., from Chicago to Dallas, and from Seattle to Philadelphia. Contact us today for more information.
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Our client, a home health business manager convicted of $2 million in healthcare fraud, was able to serve just three months of his 36-month sentence, arguing for “compassionate release” due to his age and health condition.
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