Health care fraud may mean different things to different people but to most legitimate physicians and health care service providers, it could mean a deliberate attempt to siphon government money intended for benefit programs like Tricare and Medicare that is often to the tune of several million dollars. However, for prosecutors, federal agents and government, the term health care fraud may have a broad definition since one can even be cited for health care fraud as a result of unintentional billing errors. This carries the potential for severe penalties including losing eligibility for a benefit program. It is therefore important to understand what constitutes health care fraud and what can lead to criminal or civil charges.
1. False and fraudulent claims
The federal government has one of the single most-powerful tools for prosecuting health care providers suspected of engaging in health care fraud known as the False Claims Act. This Act is a broad and elaborate statute that imposes heavy criminal and civil penalties for any false or fraudulent claim submitted for the reimbursement of federal Health care program. This involves the submission of a fraudulent or false claim by a provider “knowingly” or in circumstances where the provider recklessly disregards the truth so as to remain “willfully ignorant” of a violation of billing.
2. Billing for supplies, equipment and services not provided
Several government agencies and federal authorities can vigorously pursue allegations against providers who may be suspected of billing for supplies, equipment or services not provided to patients or what is commonly referred to as “phantom billing”. But billing for services and items not provided may also be due to coding errors such as submission of incorrect billing codes, typographical errors or in cases where administrative staff mislead patient records.
3. Prescription drug fraud
This may include health care providers, pharmacists and physicians who may be suspected of improperly administering, dispensing or prescribing medications. Prescription drug fraud investigations also target other practices such as:
- Falsifying prescriptions
- Illegal importation of prescription medication
- Drug shorting/refill schemes
- Inaccurate reporting of test results so as to prescribe unnecessary drugs
- Prescribing medications without examining patients
- Sale of fraudulent prescriptions
4. Inaccurate reporting of test results and falsifying patient records
Despite a growing need for quality health care, there are some health care businesses, medical laboratories including physicians that still engage themselves in falsifying test results and patient medical records so that they can bill for additional procedures and testing. This also misleads the federal authorities who heavily depend on data analytics to identify providers who engage in health care fraud.
5. Fraudulent/false physician certifications
Physicians are required to certify the eligibility of Medicare and other health care program beneficiaries for them to be covered for hospice care or home health.This certification is based upon a physician’s independent examination hence it must be an accurate reflection of the examination results without any outside influence or financial motive. Allegations of fraudulent physician certifications may be subject to health care fraud investigations.
It is important to hire an experienced health care fraud attorney in case your business or practice is under investigation for allegations of committing health care fraud. An attorney will help you get to the bottom of the issue before investigators can find any incriminating evidence of health care fraud against you. Contact Oberheiden & McMurrey, LLP if you are looking for experienced legal representation in medical fraud matters.