Health Care Fraud

Because health care fraud costs the United States tens of billions of dollars a year (adding up to about ten percent of total health care costs), law enforcement authorities and prosecutors are vigilant about investigating and prosecuting such abuses. In many cases, however, these authorities are hyper-vigilant, resulting in false accusations, trumped-up charges and exaggerated claims of culpability. A charge of health care fraud is no laughing matter in Houston – in serious cases you are almost certain to require the services of a top-tier Houston health care fraud attorney.

Definition

The term “health care fraud” is a catch-all term used to describe the criminal offense of intentionally submitting false health care claims to save money or make a profit. It can be committed by health care consumers, health care providers, or third parties such as medical equipment suppliers or pharmaceutical company executives.

Examples

Health care fraud can be committed in a myriad of different ways, including:

By health care consumers:

  • Making a false statement to obtain health insurance (“I am a non-smoker”, for example, or concealing a pre-existing medical condition)
  • Using someone else’s insurance card to obtain medical care, or allowing someone else to use your insurance card to obtain medical care
  • Writing and filling false prescriptions

By health care providers:

  • Billing insurance companies for procedures that were never performed
  • Performing unnecessary medical procedures and then billing an insurance company for them
  • Writing unnecessary prescriptions and billing an insurance company for them
  • Accepting kickbacks – receiving unauthorized benefits from pharmaceutical companies in exchange for over-prescribing the company’s products, for example

By third parties:

  • Committing medical identity theft (stolen physician identifiers can be used to fill bogus prescriptions and the pharmaceuticals can then be sold for recreational use, for example)
  • Billing for expensive medical equipment while actually providing less expensive equipment (by a medical equipment provider)

Penalties

Health care fraud is prosecuted under many different criminal statues, depending on the nature of the conduct. Writing a phony prescription in Texas, for example, can result in a 10-year prison sentence and a $10,000 fine. Large-scale health insurance fraud by a doctor, by contrast, could result in life imprisonment if the amounts are high enough. The dollar amount of the fraud is highly relevant to the degree of punishment that is ultimately imposed.

Defenses

The possible defenses to a charge of health care fraud are nearly as numerous as the possible fact patterns from which an individual case might be composed. Some of the more useful defenses include:

  • The decision to perform an expensive procedure was a justified exercise of medical discretion, even if it turned out to be the wrong decision.
  • The evidence against the defendant was obtained in violation of the Fourth Amendment (by breaking into the defendant’s computer without a search warrant, for example).
  • The benefits received under an alleged “kickback” scheme were minimal and could not have motivated the defendant to overprescribe the company’s products.
  • The total amount of the fraud was less than the amount claimed by the prosecution (resulting in reduced penalties in many cases)

Fighting Back

Conviction of a health care fraud charge could land you in prison and, if you are a health care professional, result in the loss of your license to practice medicine. Mario Madrid is an outstanding Houston white collar crimes defense lawyer with decades of experience in practice. As a former prosecutor and judge, as well as a certified specialist in Criminal Law, he views his clients’ cases from a multi-dimensional perspective that ordinary lawyers simply cannot match. If you have been charged with health care fraud In the Houston area, call Madrid Law, PLLC at 713-877-9400 for a free initial discussion of your case.