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White-collar crime is a nonviolent, financially motivated crime committed by someone working for the government or a business. An example of white-collar crime is health care fraud. Healthcare fraud occurs when there is an intentional submission of false information to receive greater financial benefits.
Healthcare is one of the largest industries. The United States spends approximately $2 trillion each year on healthcare. Unfortunately, the United States also spends almost $68 billion each year on healthcare fraud.
Types of Healthcare Fraud
Due to the large industry of healthcare, fraudulent activity has been rampant over the last two decades. As a result, the government has put into action task forces to diligently monitor and handle healthcare fraud. The majority of healthcare fraud occurs with Medicaid and Medicare.
There are many ways in which a business or government professional can perform healthcare fraud. A top culprit is overbilling or billing for services that are non-existent. Another common fraudulent activity is increasing the cost of a medical procedure by billing for each step of the procedure.
Mis-diagnosing or the false diagnosis of a patient in order to receive financial gain is healthcare fraud. When a physician’s office or hospital does not accurately classify a procedure with the purpose of being compensated, they are guilty of healthcare fraud.
Billing more for a service than what it is worth is called upcoding. Upcoding allows the organization to bill for more money and this is considered healthcare fraud. Kickbacks and incentives for patient referrals or tampering with deductibles and copays are all criminal activities.
Medicare Fraud Laws
The government is making it harder for people to participate in healthcare fraud. Laws and policies are set in place to limit healthcare fraud and misconduct. The following federal laws monitor healthcare fraud:
• Anti-Kickback Statute – This law prohibits a person from receiving any type of incentive, payment, or reward for referring patients.
• False Claims Act – This act prohibits submitting false insurance or healthcare claims to the United States government.
• Stark Law – The Physician Self-Referral Act prohibits physicians from referring patients to doctors and facilities in which there is a vested financial interest.
• Exclusion Statute – With this act, doctors that have a history or have been convicted of criminal crimes cannot participate in Medicare.
• Civil Monetary Penalty Law – The law states that monetary penalties and Medicare exclusion can take place for any type of government fraudulent behavior.
The laws above are all governed by the Office of Inspector General, the Department of Health and Human Services, and the U.S. Department of Justice. These are the laws that govern Medicare fraud in the United States.
Medicare Fraud Punishment
A Medicare fraud punishment or sentence is influenced by the amount of money that was falsely claimed. The maximum sentence for healthcare fraud is 10 years.
Although this is the maximum sentence in most states it can be increased if bodily injury occurs as a result of fraudulent activity. In this case, a person can face up to 20 years of prison time. If death occurs as a result of Medicare fraud, a person can face life in prison.
There are different categories of punishment and violation dealing with Medicare fraud. Violations under the False Claims Act may result in a $250,000 fine and 5 years of prison time. If the Anti-Kickback Statute is violated, you can expect 5 years of prison time and a $25,000 fine.
Punishment does not stop with fines and jail time. Medicare fraud can result in a physician losing their license or not being able to participate in healthcare programs funded by the federal government.
Medicare Fraud Defense
In some cases, a healthcare provider can be improperly charged with Medicare fraud. Honest billing mistakes or not reporting accurately can cause a red flag for Medicare Fraud.
A full investigation is required if Medicare fraud is expected. Attorneys are able to help navigate the process of making sure the Medicare fraud is accurate or if it was an honest mistake.
A Medicare fraud case can include multiple people. An investigation is required to determine who is at fault and the extent of the damages. The U.S. government has put many teams in place to protect patients and to limit Medicare fraud.