What is the Government after and why?
Increasingly, the government is focused on prosecuting healthcare, including telemedicine fraud. First, the opioid crisis led to record-setting takedown operations and widespread patient brokering investigations. Now, due to the COVID-19 pandemic, the recent focus is on telemedicine fraud and conspiracy charges. Unfortunately, as we’ve seen with other multi-agency operations and task forces, sometimes the net is cast too wide and innocent people and innocuous behavior gets swept up in government investigations.
Fraud and abuse in the healthcare system is believed to be rampant, costing the country billions of dollars each year. For this reason, the government has been especially aggressive in pursuing healthcare fraud cases. Healthcare fraud investigations are especially common in South Florida partly because of the high number of retirees here who rely on government benefits. In addition, during the COVID-19 pandemic, more providers are offering and insurers are paying for telemedicine services. The federal government is cracking down on improper use of telemedicine, boasting large scale, intra-agency criminal investigations. Defending healthcare and telemedicine fraud charges requires an attorney with highly specialized knowledge of this complex area of law.
If you have been accused of or suspect you’re being investigated for healthcare fraud, attorney Ron Herman is uniquely qualified to handle these complex cases. We are selective in the types of cases we represent, focusing on white collar offenses, such as healthcare fraud. Ron is well-known in and out of the legal community as a skilled criminal litigator who is respected by judges, prosecutors, and community leaders. He has extensive experience defending a wide range of medical and business professionals in the healthcare field. Contact us to see how we can work together.
What is healthcare and telemedicine fraud?
Generally, healthcare fraud occurs when false or misleading information is submitted to an insurer, Medicare or Medicaid in order to recover payment for healthcare services. Examples of healthcare fraud include:
- Billing for services not actually provided
- Administering unnecessary services
- Upcoding – billing for a more costly service than the one actually performed
- Unbundling – billing each stage of a procedure as if it were a separate procedure
- Accepting kickbacks for patient referrals or for certain drugs or treatments
- Billing Medicare or Medicaid and the recipient for the same services
- Providing false information in a Medicare or Medicaid application
- Self-referrals
- Forging a prescription
Telemedicine is the use of telecommunications technology to provide health care services remotely, usually by phone or video appointments. Some common telemedicine fraud allegations include individuals recruiting insured patients and submitting fraudulent prescriptions, or ordering medications that were not medically necessary. The government’s focus is to take down schemes and conspiracies where telemedicine consultations were used, for example.
State and Federal Healthcare Fraud Charges and Defenses
Because Medicare is a federal program, and Medicaid is jointly run by the state and the federal government, healthcare fraud can lead to both state and federal charges.
Under Florida law, healthcare fraud is defined as the “intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to herself or himself or another person.” In particular, the state will prosecute individuals who knowingly make, cause to be made, or attempt or conspire to make, false statements in order to obtain goods or services from the Medicaid program.
At the federal level, healthcare fraud is governed by a variety of statutes, including:
- False Claims Act – Designed to protect the government from being over charged for goods or services, including Medicare reimbursements. Under this law, a whistleblower that reports someone for defrauding the government can receive a portion of any funds that are recovered.
- Anti-Kickback statute – It is illegal to pay for or receive anything of value in exchange for referring patients covered by Medicare or other government health care program.
- Stark Law (Physician Self-Referral) – Prohibits doctors from referring Medicare patients for certain health services to any entity that the doctor, or an immediate family member, has a financial relationship with, whether an indirect investment or a direct compensation arrangement.
- Criminal Health Care Fraud Statute – Prohibits knowing and willful attempts to defraud any health care benefit program or obtain money or property under false pretenses or promises.
Examples of federal statutes charged in a common healthcare fraud indictment are:
• 18 U.S.C. 1347 — Healthcare Fraud
• 18 U.S.C. 1349 — Healthcare Fraud Conspiracy
• 18 U.S.C. 1343 — Wire Fraud
• 18 U.S.C. 1961 — Racketeering
• 18 U.S.C. 1956 — Money Laundering
• 21 U.S.C. 841(a) – Drug Trafficking
• 42 U.S.C. 1320a-7b — Anti-Kickback Statute
• 18 U.S.C. 371 — Conspiracy
In addition, the Florida Attorney General also classifies prescription drug diversion as Medicare fraud, including activities such as:
- Doctors illegally prescribing medications
- Nurses ordering medications without physician approval
- Pharmacists filling counterfeit prescriptions
- Healthcare workers stealing, selling or using patients’ medications
How can you fight charges of healthcare and telemedicine fraud? Healthcare fraud cases usually turn on whether the defendant acted with “fraudulent intent.” Known as the “good faith defense,” the key to winning healthcare fraud cases can be showing that the client acted in good faith or made an innocent error. Another defense strategy focuses on whether the federal and state agencies targeted the wrong person. For example, the defense would question whether the client had the duties and was responsible for billing, for example, or whether another person was actually the one committing the fraud.
In addition to health care fraud charges, the government frequently includes conspiracy charges too. Because these cases tend to be document heavy, with complex facts and legal issues, outside experts may need to be retained too. For example, a medical billing expert or a doctor may be required to work with the attorney to prepare for trial or other court proceedings. Anyone investigated or charged with healthcare fraud should look to retain a federal health care fraud attorney who is knowledgeable and experienced in defending against charges of health care fraud and is experience in working with such experts.
Healthcare Fraud Penalties
Violations of state and federal healthcare fraud laws are felony offenses that can lead to significant penalties, including:
- Incarceration between 1-20 years in federal prison
- Expulsion from the Medicare and Medicaid programs
- Forfeiture of medical licenses
- Loss of staff privileges
- Fines ranging from $10,000 to $50,000 per violation
- Additional fines of three times the amount claimed for each fraudulent act
Experienced Healthcare and Telemedicine Fraud Defense Attorney
Attorney Ron Herman focuses on defending white collar charges, with experience representing various parties in the healthcare field. Ron’s clients included healthcare providers, owners, managers, and entrepreneurs in the medical field, charged with billing for services not provided, submitting false claims, prescribing medications and medical equipment that were not medically needed, and related conspiracy and fraud charges. The penalties can be severe, especially in cases involving medical providers who are subject to license forfeiture if convicted. Call our office today for a consultation.
Herman Law, P.A. serves clients in Ft, Lauderdale, West Palm Beach, and throughout South Florida