FEDERAL HEALTH CARE
FRAUD
Leading Federal Health Care Fraud Defense Attorneys in Detroit
Bajoka Law — Top Federal Health Care Fraud Attorneys
WHAT IS HEALTH CARE FRAUD?
Health care fraud is financially motivated criminal activity where typically doctors or clinics charge for services that were either not medically necessary or never provided at all to their patients. Most federal health care fraud cases arise from false billings to Medicare, Medicaid or other federally operated health care organizations. Health care fraud in America accounts for over $100 billion each year. The FBI and DEA have made health care fraud a prime focus in their crime-fighting efforts. Health care fraud investigations are considered a high priority within the FBI’s Complex Financial Crime Program. If you are being investigated for health care fraud it is important to know that the federal government is not taking these cases lightly. Expect the full force of the federal government in investigating and prosecuting health care fraud cases.
WHAT ARE THE POSSIBLE PUNISHMENTS FOR HEALTH CARE FRAUD?
- Prison: Making a false statement to Medicare or Medicaid can result in a 5-year sentence for each offense. If someone suffers a serious bodily injury due to health care fraud it can result in a 20-year sentence. If someone dies due to health care fraud it can result in a life sentence in federal prison. As you can see, all the options are on the table in terms of potential prison sentences for a health care fraud conviction.
- Probation: Probation is an alternative to jail that a judge can sentence someone for a health care fraud conviction. As part of the probation, the offender will have to follow certain guidelines, may have to submit for drug or alcohol screening, and will have an assigned probation agent that they will need to stay in close contact with. Violations of probation can result in lengthy prison sentences.
- Restitution: A judge can order an offender to pay back the money improperly obtained due to their fraudulent activity. This number can easily end up in the millions of dollars.
- Fines: Anyone convicted of a health care fraud offense is subject to hefty fines. A false statement to Medicare or Medicaid by an individual doctor can result in up to a $250,000 fine per offense. False statements by organizations can result in up to a $500,000 fine per offense. Again, it is easy to see how these fines can easily end up in the millions of dollars.
- Other: A health care fraud conviction can result in the suspension or revocation of your medical license.
WHAT ARE SOME EXAMPLES OF HEALTH CARE FRAUD?
Common examples of health care fraud include:
- Billing for services not rendered
- Billing for personal expenses
- Upcoding for unnecessary medical treatment
- Being involved in paying or receiving kickbacks
- Overpricing
- Duplicate Billing
- Faking claims to receive payments
- Falsifying diagnoses
The different activities that could be present during the commission of health care fraud can lead to various criminal charges. The specific charges under the umbrella of federal health care fraud are:
- Health Care Fraud (18 U.S.C. § 1347)
- Health Care Conspiracy (18 U.S.C. § 1349)
- Mail or Wire Fraud (18 U.S.C. § 1341, 1343)
- Anti-Kickback Law (42 U.S.C. § 1320a-7b)
- False Claims (18 U.S.C. § 287)
- False Statements (18 U.S.C. § 1001)
WHAT ARE THE POSSIBLE DEFENSES?
The act of fraud requires a criminal intent to unjustly enrich oneself through the use of some sort of false claim or activity. It is the United States Attorney’s burden to prove that you had a criminal intent to defraud a national health system. A common possible defense is that of mistake. In order to rise to the level of fraud, it must be proven that the act was intentional, with the intent to defraud. What about other defenses? Were there constitutional violations? Is there even enough evidence? Does proper forensic accounting show fraudulent activity? These are just a few of the defenses and questions a seasoned federal health care fraud attorney will ask while building a proper defense for a health care fraud case.
ANY FURTHER QUESTIONS?
If you or a loved one is being investigated for federal health care fraud or have already been indicted, you might be asking yourself, what do I do now? Finding a website such as this can be a great resource, but it is not a substitute for the advice of an experienced attorney.
EXPERIENCE MATTERS
Most attorneys have never stepped foot in a federal courthouse, much less have actually been a part of a federal jury trial. Do you really want your case to be the first your attorney has actually defended in federal court? While the answer to that question might be easy, choosing the right attorney might not be as simple. The right attorney for a federal health care fraud case is not someone looking to sign up every person that walks through their door. The right attorney for a federal health care fraud case is one that has the proper experience, time, and resources to put into defending your case against the power of the government. The United States government has unlimited resources when it comes to investigating and building cases. Your first step towards leveling the playing field is hiring an attorney who brings years of successful federal criminal defense experience to the table. At Bajoka Law, we lean on this past experience to help bring future success.
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Healthcare Anti-Kickback Violations WHAT IS THE ANTI-KICKBACK STATUTE? The federal Anti-Kickback Statute (AKS) (See 42 U.S.C. § 1320a-7b .) is a criminal law that prohibits people from exchanging things of value, in order to get referrals of business that will be paid for by federal health care programs. Major federal healthcare programs include Medicare, Medicaid, and the Veteran’s Health Administration. Anti-kickback includes receiving financial incentives for referrals, free or excessively cheap rent for office space, or excessive compensation for medical directorships. Another example of a kickback includes waiving copayments. According to the Center for Medicare and Medicaid Services, illegal kickbacks have resulted in higher medical costs, overutilization of medical services, and corruption of medical decision-making. Anti-kickback laws are intended to protect the public from medical decisions that are made based on money instead of health reasons. If you are facing an alleged violation of anti-kickback laws, then it is important to speak to an experienced hea lthcare fraud attorney as soon as possible. WHAT ARE THE CONSEQUENCES OF ANTI-KICKBACK VIOLATIONS? If you are alleged to have violated federal anti-kickback laws, then you face the potential of both a criminal and civil claim. If you are criminally charged, then you face the potential of up to five years in federal prison, along with fines of up to $50,000 per offense. Further, a conviction will result in you being excluded from doing any future business with a federal health care program. The Office of Inspector General is required by law under the Exclusion Statute (See 4 2 USC § 1320a -7 ) to exclude anyone convicted of specific health care fraud crimes from doing any future participation in any federal health care programs. Federal anti-kickback laws apply to any referral source, the referral does not have to come from a physician for a criminal charge to be filed. A referral under the anti-kickback law is “any item or service for which payment may be made in whole or in part under a federal health care program.” This means that anyone who is shown to purposely send a medical provider clients with the expectation of payment that involves a federal healthcare program can result in federal anti-kick back criminal charges. HOW CAN ANTI-KICKBACK APPLY TO HEALTHCARE FRAUD CASES? If it can be shown that there was a willful payment to someone to induce or reward medical patient referrals involving a federal healthcare program, then anti-kickback charges can be part of a larger federal healthcare fraud case. In other industries, referral fees are permitted and even encouraged. In federal health care, paid referrals are against the law. Other related healthcare fraud activities include billing for services not rendered, administering medically unnecessary treatment, and falsifying diagnoses. Violations of the federal anti-kickback statute can result in a civil claim under the False Claims Act (See 31 USC §§ 3729-3733 ). The False Claims Act is a law that protects the federal government from being falsely billed or sold inferior goods or services. The civil penalty for a False Claims Act violation can be up to three times the value of the loss suffered by the federal government plus $11,000 per claim filed. A violation does not require actual knowledge, and an individual can be convicted for deliberate ignorance or having a total disregard for the truth of relevant information. Another related federal healthcare fraud statute is the Physician Self-Referral law (See 42 USC § 1395nn ). This law, also known as the Stark Law, outlaws physicians from referring patients to medical providers with whom the physician or an immediate family has a financial relationship. This only applies to designated health services that are payable by Medicare or Medicaid. There are exceptions that exist to allow self-referrals. HOW DOES THIS AFFECT ME? Hopefully, none of this affects you. But if you are currently being investigated for an alleged anti-kickback violation, or have already been charged, then this can affect you directly. Investigation and enforcement related to different variations of healthcare fraud are a high priority for federal prosecutors across the country. If you need legal help, then be sure to speak to an experienced attorney right away. FREE AND CONFIDENTIAL CONSULTATION At Bajoka Law we are proud to offer consultations that are both FREE and CONFIDENTIAL. We realize that anti-kickback cases require the proper discretion, and we will treat your situation with the utmost care and caution. It’s time you started to retake control of your life. Feel free to contact us anytime at 1-844-4BAJOKA (1-844-422-5652). You can also contact us online he re . We have three statewide offices to service you in Detroit, Lansing, and Warren MI. Your freedom could be a phone call away, but it is up to you to make that call. Our attorneys at Bajoka Law are available now to take your call and your case.
ANNUAL REPORT OF THE FRAUD SECTION OF THE DEPARTMENT OF JUSTICE Each year the Fraud Section of the Department of Justice compiles and publishes case data from the previous year to not only see what they have accomplished from an enforcement perspective, but to also recognize trends and determine where investigative and enforcement support is needed. The Fraud section focuses on white-collar crime enforcement and is made up of three litigating units, they are: The Foreign Corrupt Practices Act Unit, The Market Integrity and Major Frauds Unit, and The Health Care Fraud Unit. In addition to these units, the Fraud Section has support units that aid the three litigating units. These support units include: The Strategy, Policy, & Training (SPT) Unit, The Special Matters Unit (SMU), and The Administration & Management Unit. Between all three of these units and their support units, the Department of Justice has 161 prosecutors who investigate and prosecute these various forms of white-collar crime. In 2020, the Fraud Section as a whole charged 326 individuals with various forms of white-collar crime, which resulted in 213 convictions either by guilty plea or trial. The majority of these cases were related to health care fraud as charged by the Health Care Fraud Unit. If you are facing a health care fraud investigation, or have already been charged, then it is important that you speak to an experienced federal health care fraud attorney immediately. WHAT IS THE HEALTH CARE FRAUD UNIT? The Health Care Fraud Unit investigates and prosecutes federal health care fraud cases. A prime focus of the Health Care Fraud Unit is how opioids are prescribed, distributed, and diverted. The Health Care Fraud Unit’s main goals are to protect federal health care programs and to detect and deter illegal activity related to opioids. The Health Care Fraud Unit is comprised of 80 prosecutors, nearly half of the 161 prosecutors that exist across all three units of the Fraud Section. The Health Care Fraud Unit operated 15 different “Strike Forces” dealing with both health care fraud and opioid fraud across 24 federal districts. A Strike Force is a cross-agency collaboration between different investigative and law enforcement organizations to target specific illegal activity; in this case, health care fraud. 2020 saw one of the largest ever national health care fraud and prescription opioid takedowns in American history. The Health Care Fraud Unit continues to grow as big health care fraud takedowns continue. IMPORTANT 2020 HEALTH CARE FRAUD CASE STATISTICS In the Department of Justice Summary of 2020 Fraud Section annual report , health care fraud is at the forefront of most of the important statistics related to enforcement. Important 2020 health care fraud case statistics include: 167 total individuals charged with health care fraud 62 medical professionals were charged with health care fraud $3.77 billion in alleged losses due to health care fraud More than 29 million opioid pills were alleged to have been illegally prescribed Out of these 167 individuals charged, 144 of them were convicted by plea or trial 10 of these convictions were by a trial Since 2019, telemedicine health care fraud has also become an important focus for the Department of Justice. The Fraud Section is responsible for charging 73 individuals with telemedicine-related health care fraud, alleging more than $3.7 billion in fraud. These numbers are expected to only continue to grow with the Department of Justice seeing some of its biggest gains in the areas of health care fraud and telemedicine-related health care fraud enforcement. If you have questions related to your specific case, then it is important that you speak to an attorney for specific advice, call us at Bajoka Law so we can help.
WHAT IS TELEMEDICINE? Telemedicine is also known as telehealth, which relates to the distribution of health care services and information using internet and telecommunication services. It allows for remote clinical services which can allow a doctor and patient to have contact through webcam on a computer or cell phone. In most circumstances, telemedicine was primarily used in situations where meeting with a doctor was difficult or impossible due to distance, lack of transport, or lack of patient mobility. Telemedicine has historically also been an option to provide service during times of decreased funding or insufficient staff allowing a medical care provider to service their patients until the provider is back at normal capacity. Historically, Medicare and Medicaid only paid for telemedicine services in limited circumstances. The COVID-19 pandemic has completely transformed the availability and rate of usage of telemedicine in the United States as Medicare and Medicaid have waived many requirements and restrictions of telemedicine due to the difficulties of meeting safely in person. This has resulted in an increase of nearly 4,000 % in Medicare beneficiaries using telemedicine in the past 6 months. It is estimated that the telemedicine industry has the potential to balloon from a $3 billion industry to a $250 billion industry if current trends continue. This explosion in telemedicine use has also opened the door to various types of telemedicine-related health care fraud, which have drawn the attention of the Department of Justice (DOJ). If you are facing a federal health care fraud investigation or charges, then it is important to speak to an experienced federal health care fraud attorney as soon as possible. WHAT ARE SOME EXAMPLES OF TELEMEDICINE FRAUD? As telemedicine has exploded in popularity and usage, so have the criminal schemes and activity by health care providers trying to profit. Even before the pandemic, the DOJ was auditing health care provider’s usage of telemedicine and found that almost 1/3 of telemedicine claims were not up to regulation. Telemedicine is now being used a vehicle to help carry out various forms of health care fraud. One such example is that of illegal kickbacks. Under the federal anti-kickback law (42 U.S.C. § 1320a-7b), health care providers are not allowed to pay, induce, or receive referrals for medical services that are reimbursed by federal health care programs like Medicaid or Medicare. In a recent case, a telemedicine company allegedly promised a free COVID-19 test in exchange for a TRICARE patient’s personal information. The company then allegedly used the information to prescribe unnecessary medicine and medical equipment in exchange for millions of dollars in illegal kickbacks. It is also alleged that the patients never got their COVID-19 tests and the telemedicine company received massive payouts from TRICARE for the unnecessary prescriptions. Other illegal kickback telemedicine fraud cases have involved Medicare and Medicaid. An example of this includes a case where a telemedicine company made an agreement to receive illegal kickbacks from labs for referring completed COVID-19 tests. These examples show just a couple of the types of telemedicine fraud that are emerging since the start of the COVID-19 pandemic. DEPARTMENT OF JUSTICE TAKEDOWNS The United States DOJ recently announced the largest health care fraud takedown in our country’s history, alleging more than $6 billion in health care fraud, and resulting in over 300 people being criminally charged. Some of the main targets of this DOJ takedown were telemedicine providers. The fraud alleged among telemedicine providers in these cases includes allegations of illegal kickbacks for prescribing unnecessary opioids, genetic testing, and referring patients to substance abuse rehab centers. It is expected that the title of “largest health care fraud takedown in US history” will be short lived, as the DOJ has intensified its focus on telemedicine and are pushing significant investigation resources towards the investigation and prosecution of major federal health care fraud cases. If you are a telemedicine health care provider, it is recommended that you take proactive steps and extra compliance measures to make sure that you do not become a party to illegal activity. If you have any questions related to telemedicine-related health care fraud, then call us at Bajoka Law so we can help.
