According to the study, almost 10 percent of the spending from health care every year came from fraudulent claims. Healthcare insurance fraud is a growing crime across the US country. Prepared by James Bell
People involved in such dishonest activity use different approaches such as falsification of medical records and documents, deceptions, identity theft, etc. With this kind of act, they’ll be able to make a profit illegally. Unfortunately, some people who commit such crimes are educated and professionals, and mostly in the medical fields. Health insurance care fraud is a crime addressed by both federal and state laws, and also one that poses significant penalties.
Fraud vs. Mistake
It’s essential to know healthcare insurance fraud from simple mistakes or improper payments. To commit healthcare insurance fraud, a person must knowingly and willingly engage in a scheme or activity that includes falsification, with the intent to get some financial gain. Fraud is not the same as committing a mistake that results in a person being billed for the treatment they did not receive. By contrast, when a physician knowingly provides treatments or procedures which their patients do not need and then bills the insurance provider for those procedures to gain a profit, such action is called healthcare insurance fraud.
While any person involved in the health care procedure can commit health care fraud, it is most commonly committed by physicians in an attempt to gain more money from the insurance provider. Some fraud schemes involve filing duplicate claims, also known as double-billing, for the same service, filing claims for treatments and procedures that were never provided, billing for treatments not covered by an insurer’s policy, and even offering kickbacks for referrals.
Moreover, fraud schemes by patients include faking their medical condition to receive medications. When received, those medications will be sold in the streets. Some falsify medical claim information, while some even use someone else’s insurance information to get health care services.
State and Federal Laws
State laws concerning healthcare fraud differ considerably. Typically, state healthcare fraud laws can fall into one of three types; false claims laws (which is the most common among the three), self-referral laws, and the anti-kickback laws. Some states have laws that can address all three types of activity, while in other states, it may have only one or two.
Medicare and Medicaid Fraud
The current healthcare system in the country has both private and public health insurers, and healthcare insurance fraud can involve either of them. Medicaid and Medicare have long been targets of common fraudulent claims, and several federal laws apply to such situations. This is also the reason why a person involved in this type of fraud needs a medicare fraud attorney.
Federal law provides for both criminal and civil penalties for healthcare fraud. The difference between the two is that criminal penalties allow for prison, fines, and restitution. Civil penalties, on the other hand, only result in paying restitution. Criminal healthcare fraud charges, both at the federal and state level, can lead to severe consequences for a person convicted.
Prison. Healthcare insurance fraud is a severe offense. This type of crime can lead to lengthy imprisonment. Creating a false claim from Medicaid or Medicare can result in a 5-year imprisonment per offense. A conviction for federal healthcare fraud can result in a 10-year imprisonment per offense. If the healthcare fraud results in severe bodily injury to the patient, then the potential sentence is up to 20 years imprisonment, while committing a fraud that results in death has a possible life sentence.
Fines. A person convicted of healthcare fraud also might face significant penalties. For example, a person making a false claim in Medicaid or Medicare might face a fine of up to $250,000 per offense, while medical organizations making false claims may face up to $500,000 per offense. On the other hand, organizations that engage in multiple counts of healthcare insurance fraud can face millions and even billions of dollars in fines.
Restitution. As part of a fraud sentence, the judge can also order the accused to pay back the total amount of money they obtained using their fraudulent acts. For example, a physician who improperly billed an insurance provider for treatments not performed, and who received payment for these procedures, can be ordered to return the money to the insurance company.
Probation. A person convicted of a healthcare insurance fraud can also face a probation sentence. Probation limits the person’s freedom instead of sending them to prison. Probation usually lasts up to 12 months, though sentences of three years or more are also applicable. Those on probation must strictly comply with specific conditions, such as not associating with known felons, regularly meeting with a probation officer, maintaining employment, and not committing more crimes.
Speak to an Attorney
Healthcare insurance fraud can ruin one’s professional career and reputation and make their life incredibly difficult. In case one has been approached by federal investigators about a potential fraud case, they need to find a medicare fraud attorney and get legal advice. After all, they are the only ones that have experience with local prosecutors, courts, and criminal investigations.
About the Expert
With over fifteen years of experience, James S. Bell P.C. has forged a name as a leading United States trial attorney. Most notably, Bell obtained the largest verdict in the United States in 2017 and the ninth (9th) largest verdict in United States history against JPMorgan Chase Bank for in excess of $6,000,000,000 (6 Billion Dollars).
Bell has become a recognized legal thought leader through projects such as co-authoring an article titled “Piercing the Corporate Veil” regarding property division in divorce and features in publications such as Forbes, Inc., and Entrepreneur and has been granted recognitions such as Best Personal Injury Attorney and Litigator of the Week.
Bell is in admission with the Bar in the States of Texas, California, and New York, and obtained his undergraduate and law degrees from Southern Methodist University. He continues to serve in a wide breadth of cases, including but not limited to healthcare disputes; Qui Tam litigation; white-collar criminal defense; catastrophic injury; ERISA; business fraud; bankruptcy; professional negligence/malpractice; oil & gas; complex securities disputes; divorce; child custody; and real estate fraud cases.