What Constitutes Federal Healthcare Fraud?

 Posted on November 02, 2023 in Federal Crimes

Healthcare fraud is, unfortunately, common, costing taxpayers and patients billions annually. The federal government prosecutes healthcare fraud, with severe penalties for those convicted, including substantial fines, imprisonment, and exclusion from government programs.  

If you find yourself in a situation with healthcare fraud, a Texas lawyer can help. You should be aware of the different types of federal medical fraud.

Billing for Services Never Performed

One of the most common forms of healthcare fraud involves billing for services that never happened. Examples of this type of fraud include billing Medicare for missed appointments that the patient did not attend, billing for fake procedures or tests that were never performed, and billing for services provided to non-existent “phantom” patients. 

For instance, if a physician submits a claim to Medicare stating they provided an hour of psychotherapy to a patient when, in reality, no such session ever took place, this will very likely constitute fraudulent billing practices. Some doctors have even gone so far as to fabricate records of medical services provided to deceased homebound patients in order to bill insurers.

Misrepresenting Services and Provider Credentials

Another common type of healthcare fraud is exaggerating or misrepresenting the services performed or provider qualifications in order to increase reimbursement amounts received from payers. Questionable practices include upcoding routine services by billing codes for more complex procedures, allowing nurses or other staff to provide care. 

However, they will then go on to bill insurers as if a doctor performed the services, permitting unqualified individuals to deliver and bill for services under a licensed provider’s name, and providing as well as billing for excessive or unnecessary services mainly to drive up total charges could potentially constitute fraudulent activities.

Kickbacks for Patient Referrals

Under federal law, it is illegal for healthcare providers to accept kickbacks or bribes in exchange for patient referrals. Some examples of potentially fraudulent arrangements include taking cash payments or other forms of compensation to refer patients to specific hospitals, pharmacies, medical equipment companies, diagnostic testing labs, or treatment programs. 

Another example would be device manufacturers or distributors providing discounts, rebates, or free items and services to physicians in order to influence their decisions regarding medical equipment rental referrals. These types of practices violate anti-kickback statutes.

Prescription Fraud

Certain prescription-related activities could potentially qualify as healthcare fraud, such as billing government or private health insurance for medications that were never actually dispensed to patients. Other examples include:

• Forging or altering prescriptions.
• Taking payments or kickbacks to prescribe certain high-cost drugs wrongfully.
• Overprescribing quantities of medications.

Contact a Plano, TX Criminal Defense Lawyer

If you are dealing with a federal healthcare fraud charge, you should have legal representation on your side. Work with a Fort Worth, TX criminal defense attorney to build the most robust case possible. Call The Crowder Law Firm, P.C. at 214-544-0061 for a free consultation.