What Are Activities That Are Considered Fraud?
Some, but not all, of the most common types of health care fraud committed by PROVIDERS includes:
- Billing for a service that was not performed
- Misreporting ambulatory transport trips or mileage
- Faking a diagnosis to provide justification to perform unnecessary tests or procedures
- Misrepresenting procedures that are performed in order to receive payment for services that are not covered (such as cosmetic surgery)
- Billing for a service that costs more than the one that was performed (aka: ‘upcoding’)
- Billing for each stage of a complete procedure in order to drive up the cost (aka: ‘unbundling’)
- Accepting a kickback for a patient referral
- Waiving copays or deductibles
- Billing patients higher amounts than the copay requires
Some, but not all, of the most common types of health care fraud committed by CONSUMERS includes:
- Filing a claim for a service that was not received
- Filing a claim for a medication that was not received
- Altering a bill or receipt
- Using another persons’ insurance card to receive services
Penalties for Health Care Fraud
It is a serious matter to commit health care fraud, and federal criminal health care fraud charges can lead to serious consequences for anyone convicted.
- Prison – A conviction for federal health care fraud can result in a 10-year sentence for each offense. If the health care fraud results in serious bodily injury to someone, there is a potential sentence of up to 20 years in prison, and an act of health care fraud that results in someones death has the potential for a life sentence.
- Fines – Fines for health care fraud can range from $250,000 to more than $1 million, or even into the billions of dollars.
- Restitution – As part of a criminal health care fraud sentence, a judge can order defendants to pay back the amount of money that was obtained as a result of their fraudulent acts. This is in addition to any fines imposed.
- Probation – Anyone convicted of a health care fraud crime also faces the possibility of a probation sentence. Probation limits the amount of freedom a person has instead of sending them to prison. Probation can last 12 months through many years. Those of probation must comply with certain specific conditions, including the possibility of regular meetings with a probation officer, staying employed, not associating with known felons, and other stipulations. Violating any of these conditions can result in probation being revoked and a person having to serve the rest of their time in prison.
Defenses in Health Care Fraud Cases
- Health Care Fraud Statute – A primary element that must be proven under this statute is the intent to defraud a health care benefit program. If a person lacks specific intent to defraud a health care benefit program, the government may be unable to demonstrate health care fraud.
- Antikickback Statute – A common defense to health care fraud charges under the Antikickback Statute involves demonstrating that the business transaction fell under the safe harbor provisions of the statute. The safe harbor provisions protect (among other transactions) investment interests, referral services, relationships between providers, arrangements between providers and health plans, and relationships between providers and suppliers.
- Stark Law – The Stark Law contains a number of exceptions for potential physician self-referral situations. These exceptions include personal services, bona fide employment relationships, physician recruitment, and physicians practicing in rural areas and locations designated as Health Professional Shortage Areas.
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