Healthcare fraud covers a broad scope of activities, but is generally defined as the intentional filing of false claims for medical services in order to obtain money from healthcare programs. The claims at issue are normally related to services either not being rendered or services that are deemed to be medically unnecessary.
Forms of health care fraud include, but are not limited to:
- Billing for care that was never given
- Billing for services that are ineligible for reimbursement
- Intentionally dispensing less or more medication than prescribed
- Filing duplicate claims
- Intentionally reporting a diagnosis, procedure, and/or services incorrectly
- Employing unlicensed and unqualified staff
- Prescribing unnecessary treatment and/or prescriptions
Criminal prosecutions are initiated and pursued against targets that the government believes intentionally defrauded health insurance programs. This includes private insurance programs as well as federally funded programs such as Medicare, Tricare, Medicaid and DOL (federal workers compensation insurance) to name a few.
Healthcare fraud enforcement is a priority for the federal government as it involves millions of citizens compiled in thousands of insurance pools, billions of dollars, and in some instances may involve conduct that potentially places patients in harm’s way. The adverse effects of healthcare fraud can be long lasting and negatively impact a large number of people and companies, even those not directly involved.
Successful prosecution may result in incarceration, fines, loss of professional license, and exclusion from federal programs.
Cases of this nature are quickly becoming more commonplace. In fact, fraud, extortion, and bribery offenses account for
6.4% of federal prisoners alone.
When prosecuting these cases, the government’s goals are first and foremost, the incarceration of the convicted individual(s) and secondly, locating and recovering the assets to satisfy restitution and penalties.
Criminal healthcare charges carry significant penalties with up to ten years imprisonment and fines of up to $250,000 per count. In addition to this, federal wire and mail fraud statutes may increase penalties to up to twenty years imprisonment.
Recent Department of Justice initiatives to thwart healthcare fraud has brought on increased attention to medical practices, hospitals, labs, pharmacies, surgery centers, and MSO’s (management services organizations) among others. With this increased attention comes more audits and investigations.
It’s worth noting that many states have their own individual laws regarding complimentary insurance fraud statutes that ensure further compliance. Let us know if you have any questions regarding policies within the state of Texas by calling us at
Also, healthcare fraud may affect professional licensing. Again, this depends on your specific circumstances, area of practice, and state. You may need to protect your license with state and association licensing
The False Claims Act
The FCA is primarily used in the prosecution of civil healthcare offenses. Often these civil investigations are conducted in conjunction with a criminal investigation. This is known as a parallel proceeding.
It is crucial to have an attorney who understands the intersection of these investigations in order to protect your rights. While civil investigations are geared toward monetary judgments, criminal investigations are focused on incarcerating the alleged wrongdoer. Our attorneys understand this process and the necessary procedures to better protect your rights.
The FCA only deals with federal programs such as Medicare, Tricare, Medicaid, and DOL. In order to be found liable of an FCA infraction, organizations must “knowingly submit these false claims” or “act in reckless disregard” to current laws.
Most FCA investigations start with either government investigation or a qui tam lawsuit:
#1. Government Investigation
When the government finds billing abnormalities, there is reason to suspect fraud. From there, the process of investigation begins. The government has relied heavily on data analytics to determine who/what is an outlier when it comes to billing certain codes or servicing a specific patient population.
#2. Qui Tam Lawsuit
FCA cases may also start with a qui tam lawsuit. A qui tam lawsuit is when a whistleblower exposes a fraudulent act and files a lawsuit with the intent of the government joining in that lawsuit and investigating the alleged conduct in that individual’s complaint.
Health Care Criminal Defense Attorneys
Many healthcare criminal defense attorneys use previous cases as a basis for demonstrating their expertise and experience. Elliott Sauter, PLLC is a team of attorneys who not only have a record of handling healthcare criminal defense cases, but are in fact a firm founded by former federal prosecutors. We apply the knowledge and experience attained at the Department of Justice to assist clients that are being investigated or have been charged with a federal crime.
This experience gives us a thorough understanding of the policies, procedures, and tactics employed by investigators and prosecutors in each phase of a criminal investigation. We work with our clients to get ahead of an investigation and to resolve a matter before any indictment occurs. When indictment is inevitable or has already occurred, we will negotiate with the Department of Justice and work to achieve the most favorable results possible for our clients, or in the alternative, draw on our vast trial experience in hundreds of criminal trials to protect our client’s rights in the courtroom.
If you suspect that you are the target of a criminal healthcare investigation, it is important to act quickly to retain effective counsel.