Health Care Fraud is generally an intentional submission of false information to receive payment for medical care and services.

Most investigations and criminal charges involve the federal Medicare and Medicaid Programs. These are not the same, in many important ways. In simple terms, these federal programs are intended to let society “care” for the elderly and “aid” the poor. But there is a much longer list of relevant programs, and theories of illegal claims and conduct, than just these two examples.

Doctors and Administrators lead busy lives. They might not be sufficiently attentive to the activities of their employees. Receiving money, from public benefit plans and private insurance payments, can sometimes be alleged to be “false claims,” when the true cause is accident or mistake, or honest disagreement with regulators. A doctor’s first responsibility is in the Hippocratic Oath, promising, “to do no harm” to the patient. However, when an investigation begins, the officers do not and are not required to believe in the “presumption of innocence.”

When law enforcement agents appear, without warning, at a hospital, clinic or doctor’s office, someone has already filed a complaint and started an investigation. It could be from an unhappy ex-employee, a disgruntled patient or simply because a computer “kicked out” some recently paid claims. Our advice: do not talk to them, do not surrender your DEA license, and do insist that you want to speak to your lawyer. Sometimes, it is smart to retain a lawyer in advance, the legal equivalent of “preventative medicine.”

The anatomy of a fraud charge

Health Care Fraud is not limited to care providers. For example, Texas law protects its Medicaid funds through the Texas Medical Fraud Protection Act (TMFPA). Patients can be charged in both Texas and federal courts with Medicaid fraud by identification card sharing with someone who is not eligible for benefits, as well as by collusion with service providers to file false claims for reimbursement. Given the volume of patients and cases that physicians take on, many practices are vulnerable to a wide variety of fraud charges. Medicare and Medicaid are only two examples of where these sorts of accusations may occur:

  • Unnecessary services of items: Submitting claims for unnecessary and unneeded medical services or items.
  • Services not provided: Billing for services not provided.
  • Prescription fraud and drug diversion: Writing unneeded prescriptions, altering or forging prescriptions; and helping “patients” obtain drugs to sell and not for personal use.
  • Kickbacks: Payments for recruiting patients and for other referrals for medical services and items.
  • Doctor shopping: using slightly different names to get multiple and excessive prescriptions.
  • Federal income tax evasion: particularly, when providing “cash only” medical services.
  • Conspiracy to commit any of the above, and other offenses.

Supporting both patient health and your business

There sometimes is a fine line between operating a thriving practice and what may appear to be illegal business activity. Success may breed suspicion. If you are investigated for Health Care fraud, contact an attorney with experience in these cases to guide you. For example, (713) 236-1900.