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What Is Healthcare Fraud?

Healthcare fraud is a criminal act that involves the filing of dishonest healthcare claims to turn a profit. It is considered illegal because it exploits the healthcare system, leading to higher premiums, out-of-pocket expenses for consumers, and reduced benefits or coverage. This type of fraud violates state and federal laws and falls under “white-collar crime.”

In Massachusetts, examples of healthcare fraud can include:

  • Billing for services not rendered
  • Upcoding services (billing for a more costly service than the one provided)
  • Unbundling (billing each stage of a procedure as if it were a separate procedure)
  • Duplicate submission of a claim for the same service
  • Falsifying a patient's diagnosis to justify tests, surgeries, or other procedures that aren't medically necessary

These types of offenses can be committed against government healthcare systems, such as Medicare and Medicaid, as well as against other healthcare organizations.

Consequences of Healthcare Fraud Conviction

A conviction for healthcare fraud in Massachusetts carries both civil and criminal penalties. Civil penalties can involve fines of up to $11,000 per false claim. On the other hand, criminal charges can result in imprisonment, substantial fines, or both, depending on the nature and severity of the violation.

State vs. Federal Cases of Healthcare Fraud

State and federal healthcare fraud cases differ mainly in jurisdiction, penalties, and investigating agencies. State cases typically involve violations of state laws. State-level agencies investigate them, while federal cases include violations of federal statutes and are investigated by federal agencies like the FBI or the Department of Health and Human Services.

Penalties also vary between state and federal cases. In Massachusetts, for example, healthcare fraud can lead to imprisonment for up to five years on the state level. On the national level, however, healthcare fraud offenses can lead to imprisonment for up to 10 years or up to 20 years if the fraud results in serious bodily injury.

Federal Statutes Related to Healthcare Fraud

The federal statute concerning healthcare fraud is 18 U.S. Code § 1347. This law says that if someone knowingly and intentionally defrauds a healthcare program or tries to get benefits from such a program using false information or promises, they will be held responsible. This includes any money or property that belongs to or is managed by the healthcare program. The penalties under this law can include fines of up to $250,000 for individuals and up to 10 years in prison.

Federal laws against healthcare fraud also include the False Claims Act (FCA), the Anti-Kickback Statute (AKS), and the Physician Self-Referral Law (Stark Law).

The False Claims Act (FCA) is a federal law that imposes liability on persons and companies who defraud governmental programs. It is the primary tool used by the U.S. government to combat fraud. The FCA provides that any person who knowingly submits, or causes to submit, false claims to the government is liable for three times the government's damages plus a penalty linked to inflation.

The Anti-Kickback Statute (AKS) is a criminal law that prohibits the knowing and willful exchange (or offer to exchange) of anything of value, to induce (or reward) the referral of federal healthcare program business. Violations of the AKS are punishable by imprisonment, fines, or both.

The Stark Law, or the Physician Self-Referral Law, means that doctors cannot refer patients to specific health services covered by Medicare or Medicaid if the doctor or a close family member has a financial connection with the service provider. There are some exceptions to this rule. Penalties for physicians who violate the Stark Law include fines and exclusion from participation in federal healthcare programs.

How Can Our Healthcare Fraud Defense Lawyer in Boston Help?

A white-collar crime lawyer who practices healthcare fraud defense can provide invaluable assistance if you're accused of this type of crime. At Brad Bailey Law, our attorney thoroughly understands state and federal healthcare laws and regulations, the workings of the healthcare industry, and the tactics used by state and federal investigators.

We can help build a strong defense strategy, challenge the evidence against you, negotiate plea bargains, and represent you in court. Unlike general practice attorneys, Mr. Bailey’s intensive experience as a former state and federal prosecutor makes him uniquely equipped to handle the complexities of healthcare fraud cases.

When Should You Contact a Lawyer?

Contacting a lawyer as soon as possible is crucial if you are accused of healthcare fraud. Early legal representation can help protect your rights and give you the best chance of a favorable outcome.

Here are some scenarios when you should seek legal advice:

  • If you've been contacted by a state or federal healthcare fraud investigator
  • If your healthcare practice is being audited
  • If you've been served with a subpoena
  • If you're facing charges for healthcare fraud

Healthcare fraud is a serious offense with severe consequences. As a medical professional, it could end your career if you face such charges; enlisting the help of Brad Bailey Law can make a significant difference in your defense.

Contact us online or at (617) 500-0252 to schedule a free initial consultation about your case.

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