Health Care Fraud Cases

The recent expansion of federal health care, called “the Affordable Care Act” (or sometimes referred to as “Obamacare”), is just the tip of the iceberg when it comes to federal criminal investigations or prosecutions for supposed Health Care Fraud. For many years, we have seen federal prosecutions directed against doctors, health care providers, insurance companies and hospitals. We anticipate that the new law will cause even more such cases.

Federal prosecutors work closely with the FBI and the office of inspector General for the Department of Health and Human Services when investigating alleged health care fraud. Many states are like Georgia, and have their own, separate, Health Care Fraud Control Unit (the “HCFCU”). Together, these agencies look for fraud that comes in a variety of forms.

One method of Health Care Fraud is the old-fashioned crime of billing for services that are never provided. The medical systems in this country are so complex that it often is difficult to match up a service provided to a patient with payment for that work. Sometimes individuals or companies use this confusion to defraud the government or insurance companies. Either no medical service of any kind was rendered, or the service was not rendered as described in the claim for payment. Other times the service was previously billed and the claim had been paid.

“Upcoding” of services is another practice we see being investigated or prosecuted on a regular basis. This type of scheme involves a billing practice where the health care provider submits a bill using a procedure code that yields a higher payment than the code for the service that was truly rendered. Some examples are routine doctor visits being billed as an initial or comprehensive office visit. Other times we’ve seen group therapy being billed as individual therapy, or 30-minute sessions being billed as hour-long sessions.

In addition to the upcoding of services, we also encounter investigations and prosecutions where the government contends that our client upcoded items or equipment. For example, if an equipment supplier delivers a basic manual wheelchair, but bills the patient’s health insurance plan for a more expensive motorized version of the wheelchair, that could be Health Care Fraud.

Another common version of Health Care Fraud is when the provider makes duplicate claims for the same service or item. These cases sometimes involve a provider who submits a second claim, but who amends only a portion, most often the date of service on the claim, so that the health insurer will not realize the claim is a duplicate. In other words, the exact claim is not filed twice, but one service is billed two times, in an attempt to be paid twice for one service.

We have also been involved in cases where the investigators and prosecutors allege that our clients provided excessive services. Examples of this type of alleged fraud come in many forms, but can include a supplier delivering and billing for 30 items per week for a patient who only requires one per day. Another version is when there are daily office visits conducted and billed for when monthly office visits would be more than adequate.

One of the areas we see very often in our Health Care Fraud cases involve “kickbacks.” It is for the most part illegal if a health care provider or other person offers, solicits, pays, or accepts money, or something of value, in exchange for the referral of a patient for health care services that may be paid for by Medicare or Medicaid. Kickbacks are often paid in cash based on a percentage of the amount paid by Medicare or Medicaid for a service, but there have been reports of kickbacks that take other forms such as jewelry, free paid vacations, or other valuable items.

Health Care Fraud matters should only be handled by experts who are well accustomed to handling these types of investigations and prosecutions. A person or company facing such a situation needs to hire an attorney who is qualified to handle these complicated cases. At Kish & Lietz, we regularly handle Health Care Fraud matters, and we have been doing so for years. If you or your company is investigated for or accused of a health Care Fraud crime, we would be glad to speak with you. Feel free to call (404) 588-3991, or contact us online.