Federal health care fraud charges are covered under 18 U.S.C, Section 1347 and defined as:
- when an individual knowingly and willfully executes or
- attempts to execute a scheme defrauding any health care benefit program by
- false pretenses or representations, or
- promises to obtain money or property controlled by any health care benefit program
In simple terms, Title 18 of the United States Code, Section 1347 makes it a federal crime to defraud any health care benefit program or obtain, by fraudulent means, any money from a health care benefit program.
Like most fraud offenses, the key element of a charge of federal health care fraud is the intent to defraud.
In general, a defendant demonstrates the intent to defraud under 18 U.S.C. § 1347 where they use false pretenses, misrepresentations, or false promises to obtain either money or services to which he or she would not otherwise be entitled.
The actual mechanism of the fraud can vary depending on the type of benefit program involved or the goal of the fraud - either to obtain cash or to obtain a valuable service.
Defrauding a Federal Health Care Program
Health care fraud is often a federal crime and charges typically come about when an individual or company defrauds a federal government health care program or insurer.
In Los Angeles County as well as in other parts of California, health care fraud could also involve:
- Medi-Cal, California's government-funded health insurance program
- Medi-Cal provides health insurance primarily for low-income, elderly, and disabled California residents
For example, a defendant might be charged with falsely claiming he or she meets the eligibility criteria for a certain healthcare benefit program when in fact he or she does not.
Imagine a program which requires that the recipients of benefits must fall below a certain income level, as is common with many federal benefit programs. This is known as “means testing.”
The defendant knows they must have income of less than $50,000 annually, to pick a round number, to qualify.
The defendant further knows that he or she actually makes $65,000 annually and is therefore ineligible to participate in the healthcare benefits program.
Nevertheless, when the time comes to fill our the registration paperwork to receive healthcare benefits, the defendant falsely claims an income of $45,000 and is accordingly accepted into the program.
When the defendant receives either:
- subsidized medical treatment, or
- a cash benefit through the program
They have committed healthcare benefits fraud because of the willful and knowing false representation made for the purpose of defrauding the medical program into providing a valuable service or payment to which the defendant knew he or she was not entitled.
Health care providers, including doctors, nurses, nurse practitioners, and physical therapists, are the most common defendants in health care fraud cases.
It is serious problem in the United States, with the Federal Bureau of Investigation (FBI) indicating that it costs the country tens of billions of dollars every year.
If you have been charged with health care fraud, it is essential that you have experienced Los Angeles health care fraud attorney at our law firm in your corner as soon as possible, and throughout your entire case, to provide effective defense against your charges .
Common Types of Health Care Fraud
Health care fraud can take a variety of forms. Some of the most common examples of health care fraud include the following:
- Providing excessive services – as when a health care provider bills Medicare for services greater than what a patient actually required under the circumstances
- “Upcoding” services – or billing for services that were more costly than the services that were actually rendered to the patient
- “Upcoding” of items – or billing for items that are more costly than what the patient actually received
- Billing for services not rendered – billing Medicare for services that were never rendered or which the patient did not need; billing for duplicate services – usually involves billing Medicare twice for the same or similar services, by slightly altering bills and invoices
- Unnecessary services – filing Medicare claims for care that a patient did not need
If you are under criminal investigation or already charged with health care fraud, call a Los Angeles federal criminal defense lawyer at our law firm immediately.
Our health care fraud attorneys will need to review all the specific details in order to determine an effective defense strategy.
Do not make any statements to federal law enforcement agents as you may make incriminating statements. Remain silent.
Health Care Fraud Conspiracy - 18 U.S.C. § 1349
Under Title 18 of the United States Code, Section 1349, the offense of federal healthcare fraud as discussed above can additionally be charged as a conspiracy when:
- one or more defendants agree to commit healthcare fraud together
Once again, the substance of the conspiracy can take many forms.
To pick a relatively common example, a group of defendants might conspire and agree that they will recruit individuals from the community to claim eligibility for certain federal healthcare program benefits and then send the qualified individuals to a doctor who is also a member of the conspiracy.
The individuals in the community will receive a payment, of “kickback,” while the doctor's office will receive reimbursement from the federal benefits program for supposedly providing medical services to the recruited individuals.
In reality, however, the doctor's office does not provide the valuable services for which they claim reimbursement from the federal government.
For their role in recruiting the patients, the recruiters, or “cappers,” also receive a kickback.
In this way, the conspiracy operates by paying the various members of the conspiracy through fraudulently obtained federal healthcare benefit dollars.
In this example, every individual involved who had knowledge that the activity was fraudulent - the cappers, the recruited patients, the doctor's office, etc. - would all be potentially charged with a federal healthcare fraud conspiracy in violation of 18 U.S.C. § 1349.
Health Care Fraud is Governed by a Variety of Laws
There are a number of federal laws that criminalize conduct related to health care fraud.
For example, the Health Care Fraud Statute makes it a crime to:
- knowingly and willfully execute a scheme to defraud a health care benefit program
A violation of this law can result in a prison sentence of up to 10 years and fines of $250,000.
Similarly, the False Claims Act allows for civil liability for individuals for knowingly present a false claim to the government for payment and making a false record or statement that is material to the false or fraudulent claim. Perhaps you are a healthcare professional facing a DEA audit.
Some other federal laws that can be used to prosecute or sue individuals who engage in health care fraud include the following:
- The Anti-Kickback Statute – Federal law that prohibits the knowing and willful offer, payment, solicitation, or receipt of any remuneration, in cash or in kind, to induce or “in return for referring an individual for the furnishing or arranging for the furnishing of any item or service for which payment may be made under a Federal health care program.
- The Patient Access and Medicare Protection Act – Added provisions to the Anti-Kickback Statute, the most important of which created harsher penalties for people who illegally buy, sell, and distribute Medicare and Medicaid numbers and other health information identifiers.
- Exclusion Provisions – Federal law allows the Office of the Inspector General to exclude individuals from participating in federal health care programs. These exclusions can be required under federal law or be left to the discretion of the Office of the Inspector General.
- The Civil Monetary Penalties Law – Authorizes civil penalties for violations of the Anti-Kickback statute.
Call a federal health care fraud lawyer at our office for more information about your specific case. Health care fraud criminal cases are typically complex.
We need to conduct a thorough examination of all the evidence to start preparing a solid defense plan.
Plea agreements are a formal deal between defendant and federal prosecutor where the defendant will plead guilty in exchange for reduced charges, or to receive a lighter sentence.
Penalties for 18 U.S.C. § 1347 Health Care Fraud
A violation of 18 U.S.C. § 1347 for federal healthcare fraud is punishable by:
- a maximum of 10 years in federal prison and/or
- the imposition of a fine
If, however, the violation results in serious bodily injury to any individual, the maximum confinement time is increased to 20 years.
If the violation results in death, the maximum punishment increases in federal prison.
Section 1349 provides that a conspiracy to commit healthcare fraud may be punished in the same fashion as the healthcare fraud itself, so the maximum punishments would be:
- 10 years, 20 years, or life in federal prison depending on if the enhancements for injury or death are applicable
It should also be noted that knowledge that the fraudulent conduct is illegal, much less knowledge of the specific provision of federal law which prohibits health care fraud, is not required for a conviction under these sections.
If the defendant knows that the statements or representations they made to obtain money or services through a federal healthcare benefit program are fraudulent, that is enough to convict regardless of whether the defendant understood that their conduct was illegal.
Collateral Consequences with Health Care Fraud
As addressed in the information above, there are significant criminal penalties associated with a health care fraud conviction, including fines well into the hundreds of thousands of dollars and significant periods of incarceration.
In addition to these court-imposed legal penalties, a health care fraud conviction can have extremely severe collateral consequences as well.
For example, a conviction for health care fraud could easily result in:
- the loss of a medical license, and
- an inability to find work in the health care profession again
In addition, as this type of conviction is a matter of public record, it could have an impact on your ability to find any type of work, rent an apartment, or attend a college or university.
Because of these serious potential consequences, anyone accused of health care fraud should retain a qualified Los Angeles health care defense attorney early in the court process.
Immediate intervention by a federal criminal defense attorney at our law firm can have a huge impact on the outcome of your case.
Federal Health Care Fraud Defense Attorney
If you or a family member is charged either by themselves or as part of a larger healthcare benefit fraud conspiracy under 18 U.S.C. § 1347 or 1349, contact our experienced federal criminal defense attorneys for an initial consultation.
An experienced federal health care fraud defense attorney at our office will be able to examine all of the facts and circumstances of your case and formulate defenses, ensuring that your case is brought to the most favorable resolution possible.
Our Los Angeles federal criminal defense law firm has a history of success defending clients against health care fraud related charges.
In one case, our client was charged with a Medi-Cal fraud case where he was accused of over $10 million in improper billing.
After extensive negotiations with the prosecutor by our firm, the charges were dismissed at the end of the preliminary hearing due to insufficient evidence.
Our client was facing substantial prison time if convicted.
If you have been charged with health care fraud, it is essential that you have experienced legal representation in your corner every step of the way.
We can protect your rights in the investigative stage of the case before a formal filing, potentially negotiate a pre-indictment resolution with the government or, in an appropriate case, litigate the matter in federal court including through a federal jury trial.
To schedule a consultation with one of the health care fraud defense lawyers at Eisner Gorin, LLP, call our office today at 877-781-1570 or send us an email through our online contact form.