The Medicare system in the U.S. is a complicated and intricate system of laws and regulations that are easily misconstrued and could trap even the most conscientious and detailed medical professionals in a Medicare fraud scheme. The U.S. government carefully scrutinizes the Medicare expenses charged by physicians. The state government also scrutinizes doctors' charges and assessments as well. The government is paying the bills and, therefore, reserves the right to examine and contest anything they want. The overbearing scrutiny from federal and state law enforcement officers exposes errors that could lead to prosecution for Medicare fraud.
Musca Law's Florida Medicare Fraud defense attorneys understand the politics that motivate charging decisions. Federal and state law enforcement officers who investigate Medicare fraud claims consider themselves the guardians of the people's money. After all, our tax dollars fund Medicare, and while no one wants to see physicians and other healthcare professionals get rich while stealing from the government, honest doctors make honest mistakes. When sincere medical practitioners face federal indictments or state charges for Medicare fraud, they need tough, aggressive, and motivated Medicare fraud defense attorneys to fight the injustice of a felony Medicare fraud charge.
Medicare, Medicaid, or Tricare fraud charges are not to be taken lightly. The sentencing schemes are harsh for convictions of Medicare fraud. A person convicted of health care fraud faces prison time, huge fines, and excessive civil penalties. Moreover, the practitioner could lose his or her practice because of a wrongful Medicare fraud indictment. Even the mere suggestion that the health care professional engaged in Medicare fraud has the potential to ruin the medical practice the provider toiled so hard to create.
Medicare Fraud Defined
Medicare fraud is the submission of false medical claims to a government-run healthcare system. Some of the most recently released estimates suggest that as much as $50 billion is bilked from the system annually. That sum is astronomical, yet the government claims that its law enforcement bureaus will investigate those charges and potentially seek criminal charges against the alleged offender.
Investigators are often tipped off to possible fraud charges when the Centers for Medicare and Medicaid Services, or CMS, process a large volume of claims from one healthcare provider. Irrespective of whether the medical practitioner has an office in an area in which lower-income people reside or older generations reside, which necessarily increases the number of Medicare claims, the CMS could order an audit to verify the integrity of the claims. Thus, even the most professional medical offices run by competent staff who follow the best practices for making Medicare claims could face an audit simply because of the number of claims.
Statutory Authority to Investigate Healthcare Fraud
Federal law governs most of the Medicare fraud investigations. Federal investigators obtain their authority to investigate fraud from laws such as the federal False Claims Act, the "Stark Law," the federal Anti-Kickback law, criminal fraud law, and the civil penalties law, among others.
The overlapping authority to investigate and prosecute Medicare fraud claims on the federal and state-level permits federal and state law enforcement officers to investigate allegations of:
- submitting false claims to CMS,
- billing for services that the healthcare professional did not perform,
- creating a false identity for a patient and then billing for services rendered to the fictitious patient,
- billing for inconsequential services,
- billing for medical equipment that was not authorized by physicians,
- billing for individual tests even though procedural codes cover bundled charges,
- invoice for a higher code level than the service performed,
- ordering excessive or duplicative testing and
- implementing unnecessary medical procedures for the sole purpose of padding the bill.
Who is Subject to Medicare Fraud Investigations?
Any health care provider who submits claims to the U.S. government or state government for payment of medical series could be investigated. Some health care businesses are at a higher risk of being investigated than others. Some of the most frequently examined medical providers are hospitals, physician-owned, and operated health care centers, pharmacies, labs, and medical device providers.
All of these industries have a higher number of claims submitted to the government for payment because many, if not most, of their patients, receive governmental health insurance. Therefore, these health care providers could be audited by forensic accountants working for the government who are solely looking to uncover the existence of fraud and not necessarily prove that the submitted claims are valid.
Several governmental law enforcement agencies have the authority to investigate Medicare fraud allegations. Agencies with the power to investigate Medicare fraud include the Inspector General's Office, the Department of Justice, the Federal Bureau of Investigation, the General Services Administration, CMS, the Department of Health and Human Services, along with Medicare and Medicaid fraud investigation units.
Potential Penalties for Medicare Fraud Convictions
The federal criminal justice system is highly punitive and pushes the boundaries established by the Eighth Amendment's prohibition against cruel and unusual punishments. Penalties for a criminal conviction include a prison term not to exceed twenty years, fines, and restitution. Additionally, civil penalties include exclusion from health care programs, triple (treble) damages, fines as high as $250,000 per false claim, and payment of attorneys' fees to the government.
The government must prove the accused guilty beyond a reasonable doubt on each and every charge. However, the factual elements of each crime that the government must prove are not overwhelming. The government must simply prove that the suspect transaction was wrong. The government need not prove the accused held the specific intent to defraud the government. Rather, the prosecution must prove that the person submitted the claim ignorant of whether it was a false claim or a complete disregard for the truth of the claim.
Medicare Fraud Defenses
Any criminal defense strategy begins with a thorough examination of all of the factual underpinnings of the alleged criminal conduct. The bulk of the evidence obtained by investigators will be found in documents. Musca Law's Florida Medicare fraud defense team will dissect and analyze the data found in the reports to create a solid defense designed to exonerate the accused or resolve the case with the smallest penalty possible allowed by law. Some federal prosecutors will consider alleging civil penalties in place of seeking a criminal indictment. Therefore, it is imperative to contact an experienced Florida health care fraud defense lawyer as soon as possible.
Don't hesitate to contact our office today at (888) 484-5057 to schedule a free, no-obligation initial case consultation with one of our experienced attorneys, to determine how our legal services could best serve you and your needs.