Trying to understand the nuances of health care fraud can be a daunting task for most as government regulations and new forms of fraud change with advances in medical technology and billing practices. Read on for an overview of what constitutes health care fraud and the common occurrences that investigators are targeting as of late.
Health care fraud is a term that can be used to describe a broad range of criminal activities within the healthcare system that wastes taxpayer dollars and can have impacts on patient safety and public welfare. A common form of healthcare fraud occurs when providers bill for services which are unnecessary or not performed. This form of fraud can have a negative impact on patients, private insurers or government healthcare programs.
Illegal patient referrals, commonly referred to as kickbacks, are another form of fraud that may occur. Kickbacks are arrangements made between healthcare providers in which one party will refer the other party’s services or product in exchange for financial incentives. This practice can potentially put patients’ health at risk, because their wellbeing is not the deciding factor in what medical service they receive and can potentially result in missing out on appropriate treatment which would have helped the patients more.
Fraud may also occur between a patient and the provider, such as when a provider prescribes unnecessary medication to a patient. Prescribing unneeded medication can lead to drugs being distributed to people that are unauthorized to take that medication. This form of fraud has contributed to the Opioid Crisis that has deeply impacted our communities in recent years. Subsequently the Office of Inspector General (OIG) and now local and state level governments are heavily targeting opioid abuse. Government prosecutors have set their sights not just on Big Pharma companies, but also on smaller providers like physicians or physician groups. According to OIG, a Kentucky doctor was sentenced to 8 years and 4 months for conspiracy to unlawfully distribute controlled substances, amongst other misconduct. The provider was also required to pay $870,000 as part of his sentence.
Telemedicine fraud is another form that has recently been growing in pervasiveness. This form of fraud involves remote solicitations to patients for unnecessary durable medical equipment, genetic and diagnostic testing, and medications. These remote vendors have even gone so far as to solicit fraudulent Covid-19 vaccinations, cures, and treatments. The Department of Health and Human Services Office of the Inspector General has recently identified $6 Billion of alleged loss due to telefraud alone.
Home health services have been and will continue to remain under the watchful eye of government prosecutors. The OIG estimates that home health services error rate on medicare payments is three times higher than any other provider, so home health companies should ensure they remain in compliance with all government requirements.
Health care fraud costs the federal government billions of dollars every year, so it’s no surprise that prosecutors do not take these offenses lightly. Penalties for health care fraud can be significant; providers convicted of violating the False Claims Act (FCA) may face 5 years in prison and fines of up to $250,000. Violation of the anti-kickback statute can trigger a fine of $25,000 and a five year sentence. The civil penalties can include a $50,000 fine for each violation of anti-kickback statute and a $11,000 fine for each false claim. Additionally the OIG may pursue “treble” damages equal to three times actual loss suffered by the government.
Health care providers may find themselves facing penalties for accidental errors or careless handling of financial agreements. Early action is important to mitigate potential liability and create a strong defense against healthcare fraud. These are just a few of the latest trends in health care fraud, though is not an exhaustive list as each case has its own differentiators. If you are being investigated for health care fraud by the federal government, set up a consultation with our experienced attorneys at Padula Law Firm by calling (305) 455-5206.
