West Palm Beach
Health Care Fraud Lawyer
Joffe Law, P.A: Experienced Medicare fraud defense attorney
An individual, group, or company can commit health care fraud. At its heart, this offense arises from a misrepresentation that prompts a private insurer or Medicare to issue a payment that it normally would not do. Due to the vast amounts spent on health care, insurers and taxpayers continually demand justice for their losses. For this reason, multiple government agencies monitor health care payments to detect fraud. Those targeted by federal law enforcement should not hesitate to consult a West Palm Beach health care fraud attorney.
Types of health care fraud
Locals accused of health care fraud typically need support from a federal criminal lawyer in West Palm Beach with in-depth knowledge of the medical industry and billing practices. Anyone who has ever looked at a medical insurance statement knows that the system is complex in the extreme.
The complexity is further illustrated in the number of ways that health care fraud can occur, such as:
- billing for services called medically necessary on the basis of false medical information
- billing for services that never took place
- billing for individual services already paid for within single-service fees
- justifying payments off of falsified medical records or treatment plans
- soliciting kickbacks for provided services or medical equipment
- misrepresenting diagnoses or medical care to increase payments
Medicare fraud is a subcategory of health care fraud that involves the federal Medicare program for older Americans and Medicaid. The Centers for Medicare & Medicaid Services pay for the health services of almost 90 million adults and children nationwide. Taken together, these programs represent the largest single source of health care payments in the country. These enormous expenditures tempt people to collect payments through illegitimate means.
Recently, the Palm Beach Post reported on March 1, 2022 about for people from Palm Beach County embroiled in an expanding investigation of Medicare fraud. They were named among 10 new defendants in a case that involves an alleged $67 million in health care fraud. Twenty-year prison sentences are possible for the people who face charges of conspiracy to commit health care fraud and money laundering.
According to prosecutors, the defendants sent fake bills to the government for genetic tests and medical equipment from multiple laboratories and medical device companies. They appear to have collected millions for walkers and knee, back, and wrist braces.
When auditors study bills, they place wrongful Medicare payments into four categories:
Abuse and waste do not always equal crimes because they can arise from mistakes. Fraud and scams, however, represent intentional actions. Medicare fraud happens when physicians, pharmacists, physical therapists, or other health care providers know that they are billing for payments under false pretenses.
Do not say anything that might incriminate you. Speak with an attorney first.
How is health care fraud committed?
A great deal of creativity can go into tricking the government into issuing Medicare or Medicaid payments. Common examples of Medicare fraud include:
- double billing: Knowingly charging twice for services.
- upcoding: Choosing billing codes that pay more than the correct code for the service provided.
- unnecessary services: Collecting payment for performing services that patients did not need.
- phantom billing: Charging the government for services that never happened.
- falsification of prices: Claiming that services cost more than they do.
- unbundling: Separating services paid by a single fee into multiple services paid for by multiple fees.
- insufficient medical documentation: Failing to keep records to justify billing practices.
- ineligible beneficiary: Asking Medicare for payment for someone who does not qualify for the coverage.
The topic of ineligible beneficiaries brings up Medicare scams. People who commit Medicare scams typically try to gather Medicare membership information from real beneficiaries along with other personal information, like Social Security numbers. This information might be used to pay for someone else’s medical care or exploited in some other way.
People engaged in these scams often prey upon elderly beneficiaries. People in this age group are susceptible to fake salespeople who may scare them with threats of losing coverage. They will mislead people by saying the product being sold is part of the Medicare system when it is not.
Federal agencies that investigate these crimes
In addition to routine audits of billing activities by public or private insurers, federal authorities detect fraud when patients report strange items on their insurance statements or medical records.
Any number of federal agencies can initiate a health care fraud investigation, including:
- Department of Health and Human Services
- Federal Bureau of Investigation
- Office of the Inspector General
- Drug Enforcement Administration
- Internal Revenue Service
- U.S. Postal Inspection Service
How health care fraud investigations unfold
Irregularities detected by an auditor result in a report to the OIG. The OIG then investigates the matter further. If evidence of wrongdoing is detected, the next step is to choose between making it a civil or criminal case.
If the decision is made to pursue criminal prosecution, the FBI will become involved. A search warrant against suspects becomes likely at this stage. In many cases, the execution of a search warrant is the first time that someone knows about the investigation.
Depending on the evidence, authorities might file a criminal complaint immediately or convene a grand jury to examine whether charges are appropriate.
Legal defenses for health care fraud
Anyone who wakes up to a search warrant or has otherwise caught wind of being under investigation needs legal advice as soon as possible. A misguided attempt to deflect questions from law enforcement might later be interpreted as obstruction of justice. Guidance from a knowledgeable federal defense attorney could prevent missteps during this delicate period.
The early involvement of a federal defense attorney could prevent the filing of criminal charges. For example, a deferred prosecution agreement might be negotiated in lieu of formal charges.
When health care cases go to trial, defense strategies often leverage the complexity of medical billing and the subjective nature of medical decisions. Depending on the details, a defendant might benefit from testimony from a medical expert who justifies medical procedures. Alternatively, a West Palm Beach fraud lawyer might succeed in arguing that billing errors were unintentional mistakes not meant to deceive.
Learn how to respond to health care fraud accusations
You can expect aggressive prosecution when accused of health care fraud. By working with a lawyer, you could avoid self-incrimination and prepare a viable defense. At Joffe Law, P.A., we know how to manage criminal cases that involve complex financial records. Contact us right away for a confidential consultation about your legal concerns.