Facing Criminal Charges For Health Care Crimes

Primum non no cere, a Latin phrase meaning, "First, do no harm," is one of the primary, fundamental principles that medical professionals are taught and expected to uphold. While most health care professionals maintain this standard in caring for their patients, there are those who inadvertently or intentionally neglect this oath. Deliberate, recurrent inaccuracies in providing or documenting treatment may result in unjustified profits apportioned to medical providers, which constitutes health care fraud. Health care fraud charges can be some of the most complex and potentially devastating federal crime charges one can face.

Health care fraud charges can often be some of the most complex and potentially devastating federal crimes.  Although health care crimes vary greatly, typical areas of health care fraud include:

  • Improper Dispensing of Prescriptions ("Drug Diversion")
  • Medicaid or Medicare Fraud
  • Social Security Fraud
  • Insurance Fraud
  • Over-billing or Improper Billing
  • False Medical Claims
  • Medically Unnecessary Treatment
  • Improper Coding Practices
  • Kickbacks and Improper Benefits

Many health care cases will begin with a Government investigation, which will often involve interviewing patients and current or former employees of the medical provider. Soon thereafter, a subpoena for records will typically arrive. Government investigators may even try to interview the alleged wrongdoer.

Three of the most common health care crimes are:

1. Billing and Insurance Fraud

Pursuant to 18 U.S.C. § 1347, a person can be found guilty of health care fraud if he/she knowingly and willfully executes, or attempts to execute, a scheme or artifice (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services.

These types of cases often include over-billing, billing for services which were not rendered, unreasonable billing and unreasonable rates of services, personal kickbacks, and unnecessary treatment. Further, these billing fraud cases frequently relate to fraud concerning Medicare and Medicaid programs. Furthermore, violating the Food, Drug and Cosmetic Act or the federal Anti-Kickback Statute also constitutes a violation of 18 U.S.C. § 1347.

2.  Drug Diversion

Controlled substances and prescription drugs may only be dispensed lawfully by means of a prescription if that prescription is issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his or her professional practice. 21 C.F.R. § 1306.04(a). If a medical care provider violates this law and issues medication outside of accepted medical standards, he/she may be charged with violating federal drug laws pursuant to 21 U.S.C. § 841, and said provider faces the same punishment as any traditional "drug dealer" would.

More recently, the Department of Justice has increased scrutiny of doctors and owners of pain management facilities. These medical clinics, sometimes referred to as "pill mills," are being charged at a rapid rate for dispensing medically unnecessary pain pills. Geographically, much of the Government’s focus has been on the alleged "pill pipeline" in Florida, Georgia, Tennessee, and Kentucky.

3.  Kickbacks

The federal "Anti-Kickback Statute," found at 42 U.S.C. § 1320a prohibits the knowing and willful solicitation or receipt of any remuneration in return for referring an individual to another to receive goods or services that will be paid for by a federal health care program.  This statute is filled with potential pitfalls, and there are numerous exceptions and safe harbors, set forth in 42 CFR 1001.952.

The Government must satisfy the following 4 elements to succeed in a prosecution under this statute:

  1. existence of remuneration (which can include anything of value, such as cash, free goods or services, elimination of debt, or bartering);
  2. the remuneration was offered, paid, solicited, or received;
  3. the defendant acted knowingly and willfully; and
  4. the defendant acted to induce federal program referrals or in exchange for them.

If found guilty under the Anti-Kickback Statute, a defendant can be imprisoned for up to 5 years and face a fine up to $25,000 for each count. Further, a defendant could be barred from participation in any federal health care programs such as Medicare, Medicaid, and Social Security.

Further, according to the Association of Certified Fraud Examiners, some of the most common health care fraud crimes include:

  1. Billing for services not provided – a pattern of submitting claims to government health care plans or insurance companies without proper, legitimate documentary evidence that the stated services were, in fact, provided.
  2. Improper billing – over-billing, billing non-covered services or treatments as covered services or treatment, improperly coding services, or charging unreasonable rates for services.
  3. Misrepresenting dates of service – submitting multiple claims that indicate that services or treatments were provided on two or more separate occasions or "office visits" when they were actually provided on the same visit
  4. Misrepresenting provider of service – submitting claim forms that misrepresent who provided patient care.  Even if a claim is legitimate and reimbursable, many government health care plans and insurance companies compensate physicians at higher rates than they do for lesser-credentialed providers.
  5. Waiving Deductibles and/or Co-Payments – while some providers justify the waiving of deductibles or co-payments because they think it helps patients who cannot afford to pay, government programs and insurance companies are often the ones left with the financial burden of making up the difference, which ultimately results in higher premiums for policy holders as well as creating tax deficits.
  6. Inaccurate diagnoses or the false reporting of procedures (including "unbundling") – intentionally and dishonestly diagnosing patients with serious illnesses in order to bill for extra, unnecessary services. Unbundling refers to the practice of charging separately for certain procedures or treatments when they would otherwise be considered to be comprehensive and therefore billable at lower rates.
  7. Corruption (kickbacks and bribery) – unlawfully paying or receiving payment for referrals. Specifically, this entails referrals for services and/or treatments that are unnecessary and/or establish a "quid pro quo" relationship between or among providers.
  8. False or unnecessary dispersal of prescription medications (also known as "drug diversion") – distributing controlled substances or issuing prescriptions for any use or purposes that are unnecessary or outside of accepted medical standards. Diversion also includes the falsifying of records, theft, or the illicit sale of controlled substances or prescription medications. 

If you believe that you may be the target of a federal health care fraud investigation, contact an experienced criminal defense attorney immediately. In many cases, speaking to investigators without the presence of a lawyer is a costly mistake that could severely hurt your chances of success. Call the health care fraud attorneys at The McKellar Law Firm today at 865-566-0125.

Make An Appointment

If you believe that you may be the target of a federal health care fraud investigation, contact an experienced criminal defense attorney immediately. In many cases, speaking to investigators without the presence of a lawyer is a costly mistake that could severely hurt your chances of success.

To schedule a free initial telephone consultation with a lawyer from McKellar & Easter, Attorneys at Law, call 865-566-0125 or send us an email. An appointment can be made at any of our three offices in Knoxville, Tennessee; Nashville, Tennessee; and Atlanta, Georgia. We accept credit cards.