May Cause Jail Time: The Casualties of Healthcare Fraud

Due to the prevalence and serious consequences to defendants of white-collar crime, we’ve decided to make them the focus of our summer blog series. Let’s start July off right by discussing healthcare fraud, a far-reaching type of white-collar crime.

Healthcare fraud affects everyone: rich, poor, man, woman, children, elderly; and, prosecutors often seek severe prison sentences. Schemes typically involve fraudulent documentation, providing false information to insurance companies, including Medicare, manipulation of prescriptions, and staged accidents. Fraud is committed by physicians, chiropractors, pharmaceutical representatives, and even patients. Insurance programs, like Medicare and Medicaid, are commonly the victims.

According to the National Health Care Anti-Fraud Association, “The financial losses due to health care fraud are in the tens of billions of dollars each year.” One of the most significant categories of healthcare fraud relates to billing, either when a patient exaggerates their injury or illness to an insurance carrier, or when a physician overcharges for services or pharmaceuticals. So-called “phantom billing” refers to outright deception: billing carriers like Medicare to pay for services never rendered.

Similarly, “repeat billing” pertains to billing for a procedure multiple times when in reality it was only performed once. Medical providers may also lie about the length of someone’s hospital stay or bill for unnecessary treatments and labs. All of these claims go to the insurance carrier who, in turn, compensates the provider by overpaying for the needed or actual services rendered.

With more access to the system, medical providers can also “upcode.” For example, if someone visits the doctor with a gash on their arm needing stitches, the specific code may actually be #S49.92XA. However, to receive additional money, the doctor could code the injury as a broken arm needing surgery, listed as #S52.1, thus committing fraud.

Ever wonder why insurance premiums and deductibles are outrageous? Every day Americans are victims of fraudulent claims and debts. Even if you are not directly affected, your tax money supports government agencies who track fraud. The phrase, “one can ruin it for all” takes on new meaning when discussing this white-collar crime. The economic cost of healthcare fraud is so significant federal prosecutors often seek and judges often give draconian, life-altering prison sentences that destroy careers, reputations, and families.

As for pharmaceutical fraud, representatives may receive kickbacks or bribes, influencing doctors to buy their products. Sometimes they will disguise free dinners and lavish trips as ‘networking’ or ‘medical advice.’ In fraud cases, the pharmaceutical representative earns a substantial commission selling drugs to doctors willing to prescribe specific brands that may or may not be in the best interest of their patients.

Along similar lines, “capping” refers to bribing a medical provider for a referral, whether it be a patient, doctor, chiropractor or insurance carrier. Prosecutors do not take such offenses lightly. Those individuals targeted for such offenses should immediately contact a criminal defense lawyer.
Ultimately, healthcare fraud’s growing predominance thrives on people willing to bribe, deceive, and exaggerate. If you or someone in your network has become entangled in a scheme, either as a medical care provider, patient, pharmaceutical representative, or insurance carrier, you need to immediately contact a criminal defense lawyer. Don’t wait!

As someone highly knowledgeable about healthcare fraud, I will help you fight the charges and understand your options. I will also persuade the prosecutor to reduce and dismiss charges, mitigate the sentence, and/or assist with any situation in which the state attempts to take mandatory action against your professional license.

Bottom line: Prosecutors are cracking down! Contact me today for a free consultation.