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Healthcare Fraud


Title 18, United States Code, Section 1347

Under 18 USC §1347, anyone who knowingly and willfully executes a scheme to defraud any health care benefit program or to obtain by means of any false or fraudulent pretenses or promises any money of a health care benefit program in connection with the delivery of or payment for Health Care benefits is guilty of health care fraud. In other words, if an individual lies to get paid by Medicare, Medicaid, or any other health insurance company then he or she is guilty of health care fraud.

The government may prosecute an individual for Health Care fraud in different ways. It may allege that an individual did not provide the services claimed or that the services rendered were not medically necessary. Additionally, it may allege that the individual charged more for the services rendered or that the services were based upon an illegal kickback arrangement. For an individual to be convicted of health care fraud, the Assistant United States Attorney must be able to prove two elements:

  1. That there was a scheme to defraud or obtain money from a Health Care benefit program in connection with the delivery of or payment for Health Care benefit items or services; and
  2. That the defendant knowingly and willfully executed or attempted to execute the scheme.

Fraudulent health care schemes come in many forms. Some of the common forms include:

  • Medical identity theft;
  • Billing for unnecessary services or items;
  • Billing for services or items not furnished;
  • Up-coding;
  • Unbundling; and
  • Kickbacks.

Medical Identity theft involves the misuse of a person’s medical identity to wrongfully obtain health care goods, services, or funds. It is defined as “the appropriation or misuse of a patient’s or provider’s unique medical identifying information to obtain or bill public or private payers for fraudulent medical goods or services.” Stolen physician identifiers can be used to fill fraudulent prescriptions, refer patients for unnecessary additional services or supplies, or bill for services that were never provided.

Lebedin Kofman LLP

Russ Kofman is a founding partner in Lebedin Kofman LLP. He has extensive litigation experience defending clients accused of felonies, misdemeanors and DWI/ DUI crimes.

The Social Security act allows States to place limits on a services based on criteria such as medical necessity. Providers must ensure that the authorized services rendered meet the definition of medical necessity according to the law of the state in which they practice. Intentional billing of unnecessary services or items can lead to a conviction of health care fraud. Similarly, providers may not bill Medicaid for a covered service or item if they did not deliver the service or item. If a provider bills for something that is not medically necessary, not authorized, or an item not actually furnished, it may lead to a conviction of health care fraud.

Up-coding is understood as billing for services at a level of complexity that is higher than the service actually provided or documented in the file. Providers must only bill for the level or services or items actually furnished. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. In a case where unbundling has occurred, the reimbursement for the individual codes billed separately is higher than the reimbursement for the single comprehensive code that should be used.

Kickbacks are defined as offering, soliciting, paying, or receiving compensation to induce, or in return for a referral of patients or the generation of business involving any item or services for which payment may be under Federal health care programs. Kickbacks are illegal when it comes to federal health care programs because they can lead to overutilization, increased program costs, corruption of medical decision-making, patient steering, and unfair competition.

A conviction under 18 USC §1347 can have serious consequences. Health Care Fraud is punishable by a prison sentence of up to 10 years. Additionally, an individual who is convicted of health care fraud may have to pay up a fine of $250,000 and full restitution. If the fraud resulted in serious injury, a conviction may result in a prison sentence of up to 20 years. In serious cases where the fraud resulted in death, a conviction may result in a life prison sentence.

For more information on Healthcare Fraud, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (212) 500-3273 today.

Lebedin Kofman LLP

Russ Kofman is a founding partner in Lebedin Kofman LLP. He has extensive litigation experience defending clients accused of felonies, misdemeanors and DWI/ DUI crimes.

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