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Recent arrests shine light on health care fraud


When the Affordable Care Act -- aka Obamacare -- was passed, it gave more resources and tools to fight fraud in federal health care programs. One such tool was $350 million to hire added prosecutors and investigators for the fight against fraud. The law also made for harsher sentencing in criminal prosecutions of health care fraud and improves upon provider and supplier screenings. The ACA also boosts the sharing of data across all levels of government.

On June 18, 2016, Sylvia M. Burwell, secretary of the United States Department of Health and Human Services, announced a national Medicare fraud strike that caused charges to be filed against 243 persons for falsely billing about $712 million in false billings.

Charges against the people arrested, some of whom are based in Georgia, include:

Conspiracy to commit health care fraud -- This occurs when a person works with at least one other person on a scheme to get paid for services never rendered or normally billed at a lower billing code.

Violations of the anti-kickback statutes -- Kickbacks happen when a medical provider accepts money or significant gifts in exchange for a provider's business. One example might be a laboratory that pays a sum of money to a practice administrator for the exclusive right of providing services to a provider's patients.

Money laundering -- Criminal money enters a provider's income stream and is then returned to the criminal enterprise as a payment of dividend.

Aggravated medical identity theft -- This involves the use of a false identity in order to get medical services and products and bill a government entity for them.

Because of changes in how extensive the fraud is calculated, industry experts see longer prison terms for those convicted. ACA calculates the monetary loss based on provider charges and not Medicare allowable.

What services were involved?

The fraud schemes involved many kinds of medical treatments and services that include:

• home health care

• psychotherapy

• physical and occupational therapy

• durable medical equipment (DME)

• pharmacy fraud

What should I do if I'm charged with health care fraud?

Medicare regulations for billing are very convoluted and occasionally people in the industry are charged with fraud because the wrong code was used for Medicare or Medicaid billing. Enhanced enforcement coupled with the recent change to ICD-10 make being charged for a fraud that you did not commit a possibility.

These are widespread but serious crimes, and any defendant charged will need a competent and very experienced criminal defense attorney who focuses on white collar crimes. You may also benefit from working with an attorney who has experience prosecuting such crimes. Knowing the tactics prosecutors use to convict health care fraud defendants can go a long way toward protecting your rights and freedom.

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