Health Care Fraud Defense Attorney in Naples
Collier County Medicare fraud attorneys ready to help with your case
The Centers for Medicare and Medicaid Services reported that health care spending accounted for 17.7 percent of the nation’s gross domestic product in 2018. With such a vast amount of money circulating for health care services, fraud presents an ongoing problem. Both health care businesses and individuals may commit health care fraud. This federal offense describes the intentional use of fabricated or misleading information to obtain payment or services from private or public health insurers. The FBI along with input from other federal agencies investigates these cases. When federal agents approach people about criminal allegations, the advice of a Naples health care fraud attorney would be appropriate before making any statements due to the risk of self-incrimination.
Fraud by health care providers
Health care providers and related businesses are in a position to commit health care fraud because they prepare bills to insurers. These entities include:
- hospitals
- outpatient facilities
- nursing homes
- clinics
- physical therapists
- pharmacies
Offenders have many tactics to draw upon when committing fraud. The most common approaches are:
- billing insurers for services that were never provided
- inflating bills with unnecessary tests and procedures that were ordered due to falsified patient records
- misrepresenting medical procedures to qualify for insurance coverage
- upcoding for the purpose of billing for procedures that pay more
- billing a single procedure as multiple services
- taking kickbacks for referrals
- waiving copays and deductibles and then overbilling insurance
- overbilling patients for services already paid by a managed care plan
Penalties can be severe
The stakes are often very high for defendants in health care fraud cases. A hospital chain that had been based in Naples, Florida, had to pay a $260 million settlement. According to the U.S. Department of Justice, the hospital company had allegedly:
- overcharged government insurers by labeling outpatient or observation services as inpatient services
- inflated emergency department fees
- paid physicians for patient referrals
Criminal investigators do not solely focus on large medical institutions. A small family-run pharmacy in Naples was faking prescriptions for the purpose of collecting money from Medicare and Medicaid. The pharmacy’s owner, his brother and his mother were all convicted. The brothers were sentenced to prison, and the mother was placed on probation for 3 years.
Do not say anything that might incriminate you. Speak with an attorney first.
Consumer health care fraud
Consumers can get themselves in trouble with federal authorities as well. Consumer-level health care fraud occurs when:
- people make an insurance claim for fictional services or medication.
- people forge or alter medical bills and receipts.
- people use someone else’s medical plan to pay for services.
- people doctor shop to get prescriptions for tightly regulated medications, like opiates.
Some of these actions may feel minor and victimless when people commit them, but they still could result in federal criminal prosecution. Letting a relative use an insurance card may be viewed as an act of kindness by the person doing it, but the insurer sees it as fraud. Anyone under investigation for misuse of health insurance benefits may need guidance from a health care fraud lawyer. Legal representation may counteract aggressive enforcement and give an accused person a chance to fix honest mistakes or negotiate a settlement.
Closer look at common forms of health care fraud
The complexity of the health care and insurance systems invites criminals to be creative. Despite the wide range of possibilities, fraud most often takes shape in the following ways.
- Upcoding: Medical providers and insurance companies use a coding system to describe the services delivered on their bills. Upcoding is the term for selecting a code for something that pays more than the code for what was actually done. For example, a code for a surgery performed in an inpatient hospital setting may compensate the provider more generously than the code for the same surgical procedure performed at an outpatient facility. Coding the outpatient surgery as an inpatient surgery represents upcoding. Although this could happen by mistake, an ongoing pattern of upcoding could attract the attention of an insurer’s fraud unit and criminal prosecution.
- billing for services not provided: Also known as phantom billing, this action represents a classic form of fraud in that the offenders lie to obtain payment. Providers send private insurers, Medicare or Medicaid bills for services that they never performed. Offenders may document appointments that never really happened and list procedures for people who were never there. In other cases, the patient was real, and some procedures took place, but the provider pads the insurance filing with fictitious claims for tests, medical devices or other care.
- Patient identity fraud: Identity theft is very common in credit card fraud cases, but it has become increasingly prevalent in the realm of health insurance. Patient identity fraud happens when someone voluntarily lets a friend or relative use insurance information or someone steals the insurance information without the account holder’s knowledge. Some cases involve hackers who steal medical and insurance information for profit.
Comprehensive legal assistance for health care fraud cases
Health care providers convicted of Medicare or Medicaid fraud may lose the privilege of billing these services in addition to paying fines and other penalties. The False Claims Act authorizes prison terms up to 5 years for individuals who engage in fraud as well as fines up to $250,000. Employees may find themselves accused of this conduct when they thought they were following their employers’ lawful instructions. Others might make mistakes that appear to be a fraud scheme when in fact they were caused by misunderstanding complex coding and billing rules.
Due to the extensive documentation at the heart of these fraud cases, people under investigation may benefit from legal counsel provided by Joffe Law, P.A. We have the resources and experience to analyze complex evidence and prepare thorough defense strategies. Our office in Naples is a local source of confidential advice and representation to people who have been contacted by law enforcement or have already been arrested.