Health care fraud is a major government priority right now. The Department of Justice, the Department of Health and Human Services’ Office of Inspector General and local Attorneys General are spending tremendous resources investigating and vigorously prosecuting health care fraud cases. The investigators often use confidential informants, previous employees and others with potential inside information to assist in the investigation and prosecution. As a result, incidental errors or negligence are often identified as potential fraud. The Medicare/Medicaid billing manuals/procedures are not easy to understand and often coding errors and simple misunderstandings lead to adverse consequences. With significant increases in funding from the federal government for health care fraud audits, health professionals are often faced with intrusive investigations.

For over 30 years, Philadelphia Criminal Defense Lawyer Hope Lefeber has been an aggressive advocate for her clients’ constitutional rights. She defends doctors, home health agencies, pharmacists, urgent care center employees, physician’s assistants and other individuals involved in the delivery of medical care. As a former Enforcement Attorney for the United States Securities & Exchange Commission, Ms. Lefeber is an experienced federal criminal defense attorney with in-depth knowledge of federal law and procedure. She has been consistently honored as a Pennsylvania Super Lawyer, as one of the Top 100 Trial Lawyers by the National Trial Lawyers Association, and as one of the Top 10 Criminal Defense Attorneys in Pennsylvania by the National Academy of Criminal Defense Attorneys.

Examples of Health Care Fraud

  • Kickbacks, Referral Fees
  • Submitting false claims to CMS for payment
  • Billing for ghost patients
  • Billing for services not provided
  • Billing for equipment not provided
  • Up-coding
  • Lack of medical necessity
  • Utilization of excluded providers
  • Making false statements on applications or contracts to participate Medicare or Medicaid program

Healthcare Fraud Charges and Defenses

Healthcare fraud is investigated by the FBI, DEA, and OIG and is prosecuted by the United States Attorney of the Department of Justice (DOJ). Healthcare fraud cases may be prosecuted under:

Prosecutors are targeting physicians, pharmacists, compound pharmacies and other healthcare providers that they suspect are improperly prescribing, dispensing and administering prescription medicines. In addition, for medical services, prescription medications, or healthcare supplies or equipment to be eligible for Medicare or other federal program reimbursement, they must qualify as “medically necessary.” Services are considered medically necessary when they are “needed to diagnose or treat an illness, injure, condition, disease or its symptoms and that meet accepted standards of medicine.” Whether or not a provider has conformed to this standard can be a grey area that is ripe for prosecution.

When medical practices, clinics, and other healthcare providers falsify patient records in order to bill higher amounts, or routinely bill higher volumes or amounts than the regional or national averages, this billing issues can trigger investigations.

The False Claims Act is one of the most powerful tools that the federal government has for prosecuting healthcare fraud. This Act is an extraordinarily broad statute that imposes both civil and criminal liability for any “false or fraudulent” claim submitted for federal healthcare program reimbursement. The determination of was is “false” is really subject to much abuse by the prosecution. False claims refers to all coding errors, billing errors, certifications etc. that a provider makes in connection with a claim for payment. The regulatory schemes that govern reimbursement are extremely complex and are being used by the prosecution to criminalize violations of these rules.

Under the Medicare Anti-Kickback Statute, it is illegal for any healthcare provider to “knowingly and willfully” offer payment or remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in-kind to any person to induce a patient referral under a federal health care program. In addition, the Stark Law prohibits any transaction that qualifies as a “physician referral” to any entity with whom the physician has a financial relationship.

People charged with healthcare fraud will often face additional criminal charges, including:

In addition to serious criminal penalties, prosecution for healthcare fraud can lead to significant collateral consequences such as:

  • Exclusion from participation in federal and state healthcare programs such as Medicare and Medicaid
  • Professional discipline
  • Loss of a professional license
  • Loss of hospital privileges
  • Immigration problems
  • Inability to earn a living

Defending Federal Health Care Fraud Charges

What initially presents as a simple investigation into billing issues and irregularities is serious, as it often leads to formal indictments. In addition, providers can lose their ability to bill for health care, can have bank accounts frozen and may owe enormous penalties. If you or your business is being investigated for healthcare and/or insurance issues, it is critical that you call an experienced federal criminal lawyer immediately.

Hope Lefeber will investigate every aspect of your case and, together with you, will plan a strategy employing forceful advocacy and exacting preparation designed to obtain the best results. If necessary, Ms. Lefeber will use a team of highly qualified experts and investigators to investigate and prepare for trial. This is crucial in order to level the playing field as the government will use its extraordinary resources to prosecute these crimes.

Contact Experienced Health Care Fraud Attorney Hope Lefeber

If you are facing federal charges, having a lawyer who is highly skilled in healthcare and insurance fraud is critical to your defense. To get representation from a highly skilled defense attorney, contact the Philadelphia law office of Hope Lefeber by calling 610-668-7927 or completing our online form. Consultations are free and confidential.