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Understanding Healthcare Fraud

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Doctor Taking a Bribe

Healthcare fraud is actually very common and is normally conducted on a very large scale. According to the Office of the Inspector General (OIG) and HHS, the largest healthcare fraud in the U.S. resulted in charges against 400 individuals in 41 federal districts for fraudulent schemes totaling $1.3 billion.

The charges for healthcare fraud can range from high fines to long-term prison sentences. If you have been charged with fraudulent schemes in the healthcare sector, be sure to hire a federal criminal defense attorney to help you counter the charges against you. Here is a general overview of what healthcare fraud is, the different types under the law, and the implications of facing these charges.

What Is Healthcare Fraud?

Healthcare fraud is a kind of fraud that involves using the healthcare system in a deceitful way in order to earn profit from it. This fraud can be committed by a medical provider, insurance company, or an individual.

Healthcare fraud affects insurance rates daily and causes the premiums that people pay to increase to make up for the insurance firms' losses. When such fraudulent activity is performed by a healthcare provider this may not only affect their license but also the healthcare of patients in their facility.

Types of Healthcare Fraud

The different types of healthcare fraud can be categorized depending on whether they have been performed by medical providers, individuals, or insurance companies. The goal of all of these types of fraud is to get medical care with invalid insurance. The different kinds of healthcare fraud are:

Fraud Involving Medical Providers

  • Offering services that are not included in a patient's insurance policy and billing for a service which is covered
  • Falsifying the diagnosis of a patient to justify procedures such as surgeries that are not included or that are not necessary
  • Duplicate submission of claims for the same services when they were only offered once
  • Billing for offerings or procedures that were not provided to a patient
  • Billing for different and costlier services than the ones that have actually been rendered
  • Billing every step of procedures as one would separate procedures

Fraud Involving Individuals

  • Exaggerating claims
  • Giving false information to receive medical coverage
  • Using someone else's insurance
  • Faking or staging an accident so you can receive medication, care, or reimbursement for your expenses
  • Going to different doctors so you can get multiple prescriptions
  • Failing to remove a person who is not eligible from an insurance policy
  • Adding someone, using false information,to an insurance policy though they are not eligible for coverage

Fraud Involving Insurance Companies

  • Avoiding state insurance regulations by selling insurance they are not permitted to sell
  • Taking premiums for policies that they have no intention of paying
  • Failing to pay for services, prescriptions, or procedures that should be covered

Distinguishing Between Healthcare Fraud and Mistakes

Some people have trouble distinguishing between healthcare fraud and mistakes. A federal crimes attorney will help you tell between healthcare fraud and mistakes. For acts to be deemed as fraud, they must have been done intentionally with the aim of defrauding. Mistakes arise when a person, insurance company, or healthcare provider accidentally makes errors in payment, creates improper bills, or omits important information.

For example, a patient may receive a bill for treatment they did not get. This may be as a result of an error in the billing system. However, if a doctor knowingly bills the patient's insurance for a treatment they did not get, and they get paid for what they did not earn, they are guilty of healthcare fraud.

Penalties for Healthcare Fraud

All fraudulent activities are classified as crimes. In this case, you will need a criminal defense attorney to help you fight the charges against you. The charges for healthcare fraud are severe depending on the type of activity committed and the amount of money obtained under false pretenses. Even though a person does not succeed in their fraudulent scheme, they may still be considered guilty and punished.

Healthcare fraud is, in most cases, considered as a felony. The penalties for this crime include restitution, fines, and imprisonment for one year. Additionally, an individual or entity may face a civil lawsuit for this felony. The victim of healthcare fraud may sue the accused party in a civil court and get compensation.

In some jurisdictions, the victims of healthcare fraud sue for up to triple the amount the accused gained from their fraudulent scheme. The accused may also be required to pay for punitive damages.

If a healthcare provider or individual is involved in healthcare fraud, they risk losing their benefits or the right to be involved in the plan. This means they are no longer eligible to accept that specific insurance. For individuals, this translates to losing their health insurance. This makes them ineligible to get that specific plan from any other insurance provider.

If you are accused of healthcare fraud, whether as a healthcare provider, insurance company, or individual, it is imperative that you seek legal assistance to avoid facing severe penalties. A federal crimes attorney is your best chance of getting a reduced sentence or avoiding punishment all the same.

Turn to the aggressive and effective federal crimes attorneys at Foley Griffin. With over 75 years of collective experience, we aren’t afraid to go to bat for our clients in court. We can help you determine your options and work with you to get the best possible outcome.

Contact Foley Griffin at (888) 966-8480 to for aggressive representation in your corner.

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