Healthcare fraud is a serious issue in New York. Reported cases have surged in the past decade: according to a recent article in the New York Post, as many as three million people in this state may be fraudulently accessing Medicaid and other public health insurance benefits at an estimated cost of $20 billion a year. With numbers like these in the headlines, federal authorities are cracking down, even when the evidence is questionable.
Many people don’t realize how steep the potential penalties for fraud can be. If convicted, you could spend up to 20 years in federal prison, pay millions in fines, restitution and forfeiture, lose your license, be unable to participate in Medicaid or Medicare, and go through life with a felony on your record. You should immediately retain a healthcare fraud attorney if you or someone you know is under investigation for health care fraud.
Understanding Health Care Fraud Charges
Federal healthcare fraud cases in New York are typically prosecuted under 18 U.S.C. §1347, which makes it illegal to knowingly and willfully execute, or attempt to execute:
- A scheme to defraud a health care benefit program, which could involve submitting false claims to Medicare, Medicaid, or private insurance providers.
- A scheme to obtain money or property through false pretenses through health care program participation. This provision applies when someone lies or misrepresents information to obtain payments or benefits they otherwise wouldn’t qualify for.
Healthcare fraud isn’t limited to doctors and medical professionals: anyone involved in the system can be charged. Hospital administrators, billing company staff, pharmacists, or even patients accused of providing false information to obtain treatments or prescriptions can all be held criminally liable.
The key element in these cases is intent. The government must prove that the accused person knowingly and intentionally misrepresented facts to receive benefits they were not entitled to. Innocent mistakes, such as coding errors or paperwork mix-ups, are not typically considered fraud unless they were done deliberately.
Common Examples of Federal Health Care Fraud
Healthcare fraud takes many forms, and it’s not always as obvious as outright lying on insurance claims. Many schemes seem like routine business practices but are actually illegal under federal law. Here are some of the most common types of federal healthcare fraud:
- Billing for Services That Were Never Provided: This happens when a healthcare provider submits a claim for medical treatments, procedures, or tests that never actually occurred. It could be as blatant as billing for an appointment that never took place or as subtle as exaggerating the details of a procedure to receive higher reimbursement.
- Upcoding: Upcoding occurs when a provider bills for a more expensive medical service than what was actually performed. For example, if a patient received a routine check-up but the provider bills for a more advanced procedure, it constitutes fraud.
- Unbundling: Some medical procedures are supposed to be billed together at a lower rate. Unbundling is when a provider separates those health services and charges for each one individually, resulting in a higher total payment. This practice is intended to increase reimbursement from insurance companies.
- Kickback Schemes: Federal laws like the Anti-Kickback Statute prohibit medical professionals from receiving or offering any form of financial compensation in exchange for patient referrals. If a doctor refers patients to a particular lab, pharmacy, or specialist in return for a financial reward or gifts (patient steering), it’s considered an illegal kickback arrangement.
- Falsifying Patient Diagnoses: Some medical providers manipulate patient records to justify unnecessary tests, health care services, or prescriptions. This federal offense can lead to inflated insurance claims and may even put patients at risk if they receive unnecessary treatments.
- Prescription Drug Fraud: Prescription fraud can take many forms, from doctors writing unnecessary prescriptions for controlled substances to patients engaging in “doctor shopping” to obtain multiple prescriptions for the same medication. Fraudulent pharmacies that dispense medication without proper authorization are also part of this category.
- Performing Medically Unnecessary Procedures: This type of fraud involves doctors or health care facilities conducting procedures or tests that patients do not actually need, solely to generate higher insurance payouts.
- Identity Theft and False Claims: In some cases, fraudsters steal patient identities to submit fake claims to health insurance companies. This federal crime can leave victims facing unexpected medical bills and disputes over coverage.
Even if you were believe you were unknowingly involved in a fraudulent scheme, you could still face criminal charges. It’s critical to consult a knowledgeable attorney if you suspect you’re under federal investigation.
Criminal Penalties for Health Care Fraud in New York
Most health care fraud statutes carry a maximum sentence of 10 years (18 U.S.C. §1347, 18 U.S.C. §286, 18 U.S.C. §669). Sentences can vary depending on the severity and scope of the fraud. For example:
- Certain fraud-related criminal offenses, like making false statements (18 U.S.C. §287, 18 U.S.C. §1035), have a five-year maximum sentence. They typically involve falsifying information on health care claims or misleading regulatory agencies.
- If wire fraud or mail fraud is involved, jail time can increase to 20 years. This is because fraud that involves electronic communications or mail transactions is considered especially serious under federal law.
Anyone convicted of federal health care fraud in New York is often required to repay fraudulent gains and pay criminal fines amounting to hundreds of thousands or even millions of dollars. A conviction could also mean losing your medical license, being barred from working in the healthcare industry and facing lifelong employment difficulties.
A healthcare fraud conviction doesn’t necessarily mean someone will serve the full sentence, but the higher the maximum penalty, the longer the potential period of incarceration could be. Prosecutors also consider factors like the amount of money involved, the number of people affected, and whether the fraud led to patient harm when recommending a sentence. For example, someone facing a 10-year maximum sentence could end up serving six or seven years if patients were harmed in the process.
How Can A Health Care Fraud Defense Attornes Help?
If you’re facing a charge of healthcare fraud, having the right attorney early in the process is critical. Many people make the mistake of waiting too long to get legal help. By the time a lawyer steps in, the government has often been investigating for years. It’s essential to hire a criminal defense attorney as early as possible.
A dedicated healthcare fraud defense attorney will provide a wide range of legal support, including:
- Conducting a Thorough Case Assessment: Your criminal defense lawyer will examine all aspects of the case to identify inconsistencies or errors in the prosecution’s claims. This includes everything from reviewing billing records to interviewing witnesses.
- Identifying Legal Defenses: An experienced attorney will put together a valid defense strategy to challenge the charges. Depending on the allegations, they may seek to demonstrate a lack of intent, prove a misunderstanding, or show that the accusations are based on flawed data.
- Engaging in Strategic Negotiations: A skilled lawyer can negotiate with prosecutors to seek reduced charges, minimize penalties, or even work toward case dismissal when possible.
- Representing You in Court: If your case goes to trial, a defense attorney will cross-examine witnesses, present evidence, and make compelling arguments to achieve the best outcome.
- Protecting Your Professional Future: A conviction for health care fraud can have career-ending consequences. An attorney will work to protect your professional license, reputation, and future employment opportunities.
Can You Be Charged With Health Care Fraud Even If You Didn’t Personally Submit False Claims?
Yes. You can still face charges if you were involved in any part of a fraudulent scheme even if you weren’t the one submitting false medical claims. Federal prosecutors focus on the bigger picture, meaning they don’t just go after the individuals filing the paperwork; they look at anyone who knowingly played a role in the possible fraud.
Potential targets can include employees who processed questionable health care claims, supervisors who turned a blind eye, or business owners who benefited financially from fraudulent activities. If you are accused of assisting, encouraging, or knowingly allowing fraudulent claims to be submitted, you could be held responsible. Even passive involvement, such as failing to report known fraud, can sometimes lead to legal and financial consequences.
What You Should Do If You Suspect You’re Under Investigation
If you think you’re being investigated for healthcare fraud, the first and most important step is not to speak to investigators without an attorney. Even if you believe you’ve done nothing wrong, anything you say can be used against you. Investigators may seem friendly or just “looking for information,” but their goal is to build a case.
If you believe you are under investigation, contact an experienced healthcare fraud defense attorney immediately. A lawyer can help you understand your rights, guide you on how to respond to inquiries and ensure that you don’t inadevertently incriminate yourself.
Here are a few additional steps to take if you suspect you’re under investigation:
- Do not destroy or alter any records. Deleting emails, modifying files, or getting rid of documents can make things worse and may lead to additional charges.
- Be cautious about who you talk to. Even casual conversations with colleagues, friends, or business associates can be twisted and used as evidence.
- Gather and organize your documents. If you have access to billing records, emails, or other relevant files, keep them organized. Your healthcare fraud lawyer will want to review them.
- Avoid making assumptions. You might not know the full extent of the investigation, so don’t try to guess what law enforcement knows. Focus on protecting yourself legally.
The earlier you get legal help, the better prepared you’ll be to handle the situation.
Defenses Against Health Care Fraud Charges
If you are facing healthcare fraud charges, several legal defenses may apply to your case. Here are some common strategies an experienced attorney might use:
- Lack of Intent: One of the key elements in a fraud case is proving intent. If you made an honest mistake in billing, coding, or record-keeping, that’s not the same as committing fraud. Prosecutors must show that you knowingly and willfully engaged in deception.
- Misunderstanding of Regulations: Healthcare laws and billing guidelines are complicated. If errors occurred due to a misinterpretation of regulations rather than an attempt to defraud, your attorney can present the cause of the error as part of your defense.
- Insufficient Evidence: The burden of proof is on the prosecution. If they lack solid evidence linking you to fraudulent activity, your healthcare fraud lawyer can argue that the case should be dismissed or that there’s reasonable doubt.
- Lack of Direct Involvement: If you weren’t the one submitting claims and had no actual knowledge of fraudulent activity, your attorney can demonstrate that you weren’t complicit in the alleged scheme.
- Entrapment or Government Misconduct: In rare cases, an individual may be lured into criminal activity by an undercover agent or law enforcement. If entrapment occurred, it could be a strong defense against charges.
Each case is different. The best defense strategy will depend on the details of the charges. Your attorney can analyze your case, identify weaknesses in the prosecution’s argument, and develop a plan to fight back.
Speak to Our New York Federal Health Care Fraud Attorney Right Away
If you’re under investigation for healthcare fraud, don’t wait until you’re charged to seek legal representation. The sooner you have an experienced attorney on your side, the better your chances of building a solid defense.
At ZMO Law PLLC, we know how serious these charges are, and we can help fight them. Our experienced legal team has successfully defended many clients facing complex federal fraud charges. Our criminal defense lawyers understand how prosecutors build their cases, and we use that knowledge to protect our clients. If you or a loved one is facing healthcare fraud charges, contact ZMO Law PLLC today. Your future is too important to leave to chance, so we’ll be there when you need us.