Health Care Fraud
Michigan Criminal Defense Attorneys
Annually, health care fraud adds up to billions of dollars. While the actual amount lost to fraud is unknown, the estimates range from 3% of all health care expenditures to 10%. The Kronzek Firm attorneys have the right combination of trial skills, medical litigation, and auditing knowledge to assist people facing prosecution for crimes related to health care.
Under federal law, health care fraud is knowingly and willfully executing a plan to defraud a health care benefit program or to falsely obtain property from a health care benefit program and is connected with the delivery or payment for health care services or products.
The maximum penalty is 10 years in prison and a fine up to $250,000.If bodily injury results, the maximum penalty is 20 years in prison. In cases of death, the maximum penalty is life imprisonment or any term of years.
Provisions under the Social Security Act
The Social Security Act contains specific provisions designed to prevent Medicare and Medicaid program related fraud. First, the Office of the Inspector General (OIG) at the Department of Health and Human Services has authorization to impose civil penalties and assessments on individuals, including agencies, organizations, or other entities, who engage in prohibited conduct regarding federal health care programs. This includes penalties for knowingly presenting to a state or federal employee a fraudulent or false claim.
If services are not provided as claimed, severe penalties can be assessed. The same is true if claims were made as part of a pattern of providing services or items that the provider knows or should know are not medically necessary. Additionally, making payments to doctors to reduce or limit services is also not allowed. The Patient Protection and Affordable Care Act amended the prohibitions to include the following: individuals who knowingly (a) prescribe or order a medical item or service during a period excluded from a federal health care program when it is known or should be known a claim will be submitted under the program in question; (b) create or use a false record or statement that is material to a fraudulent or false claim for payment for items and services rendered under a federal health care program; (c) make or cause omissions, false statements, or misrepresentation of a material fact in any bid, application, or contract to enroll or participate as a service provider or supplier under a federal health care program; (d) know there is overpayment and not report and return it as required; or (e) fail to grant the OIG timely access for investigations, audits, etc.
The maximum civil penalties for such activities are up to $10,000.00 for each service or item claimed, up to $50,000.00 under specific circumstances, treble damages, and more.
The Social Security Act also provides criminal penalties for violations involving federal health care programs. Knowingly and willfully making specific false statements and representations is prohibited. This includes making or causing to be made false statements or representations in applications for payments or benefits—or in the determination of rights to benefits or payments. Additionally, a person may be criminally liable for concealing an event that affects an individual’s right to receive a payment or benefit with intent to fraudulently receive an amount more than is due or when none is authorized or to convert the payment or benefit to aid a person other than the one intended.
For such violations, where a service or item was provided and payment is or may be rendered under a federal health program, felony charges may result. The maximum criminal penalty is up to five years in prison, a fine up to $25,000.00, or both. Other individuals involved in providing false information may be charged with a misdemeanor with a maximum penalty of one year imprisonment and a $10,000.00 fine.
Exclusion from Federal Health Programs
Furthermore, one of the most severe penalties is exclusion from federal health programs, which is mandatory in some cases and permissive in others. Mandatory exclusion occurs after conviction of certain offenses, including crimes related to the delivery of a service or item under Medicaid, Medicare, or a state health care program; crimes related to abuse or neglect of patients connected with the delivery of a health care service or item; or a felony related to illegal manufacture, distribution, prescription of or dispensing of a controlled substance. The OIG has permissive authority to exclude a person or entity from a federal health program under many circumstances, including misdemeanor convictions for theft, fraud, embezzlement, financial misconduct, or breach of fiduciary duty; convictions related to obstruction or interference of a criminal investigation; and suspension or revocation of a health care practitioner’s license for reasons related to professional performance, competence, financial integrity, and more.
The Anti-Kickback Statute
Additionally, a person may be charged with a felony for knowingly and willingly offering, paying, soliciting, or receiving anything of value in exchange for a referral or to generate business—either directly or indirectly—under a federal health care program. Actual knowledge or specific intent to commit a violation is not required. This also includes the offer of anything of value in return for leasing, purchasing, ordering, or recommending such service or item that is reimbursable under a program. However, there are several statutory exceptions.
Violators face a maximum penalty of five years in prison, a fine up to $25,000.00, and exclusion from federal health care programs for up to a year.
If you need aggressive Medicare fraud defense, The Kronzek Firm is available to assist you. We practice in all state and federal courts in Michigan’s Lower Peninsula and have extensive experience and success.
Contact us about your legal matter today! Call us at 1-866-766-5245.