Healthcare Fraud FAQ

Tremendous resources are expended by insurance companies and the state and federal governments to investigate and prosecute healthcare fraud. If you or your organization has been targeted by investigators, contact Hilder & Associates, P.C., as soon as possible. Our white collar crime defense lawyers have the extensive knowledge and resources to safeguard the rights of medical providers facing fraud allegations.

What constitutes healthcare fraud?

Generally, for a person to be convicted of healthcare fraud, the government must prove that the accused individual knowingly engaged in a plan or activity to provide false information with the intention of achieving financial gain.

The mere fact that an omission, mistake or improper payment occurred does not necessarily constitute fraud. Medical providers are subject to complex requirements and restrictions with regard to insurance and billing, and innocent mistakes are common.

However, state and federal laws exist to combat various forms of healthcare fraud, including:

  • Filing insurance claims for services not rendered
  • Double-billing for the same service
  • Paying kickbacks for referrals
  • Self-referrals
  • Billing for treatments not covered by an insurance policy
  • Billing for phantom patients
  • Providing medical services that the provider knows are unnecessary, then billing the insurer for the unnecessary services

How is healthcare fraud investigated in Texas?

Healthcare fraud is investigated by multiple government agencies, including the FBI, the Medicaid Fraud Control Unit and the Texas Health and Human Services Commission's Office of the Inspector General. These federal and state agencies often collaborate and share information to investigate possible healthcare fraud.

Medicare and Medicaid billing practices are closely monitored by government auditors, and multiple errors in billing can trigger further investigation. There is also a powerful incentive for whistleblowers to contact authorities about possible Medicaid or Medicare violations, as a whistleblower could stand to receive a significant percentage of the amount of money recovered by the government.

What should I do after being contacted by a government agency?

Whether you have received notice of an audit or law enforcement officials have raided your office and seized documents, it is crucial that you seek legal counsel as early as possible in the process.

At Hilder & Associates, P.C., we help doctors and other medical providers avoid prosecution by conducting internal investigations and ensuring that the administrative process is followed. This stage prior to the filing of any fraud charges is often critical to mitigating negative consequences and helping medical providers stay in business.

Our attorneys also have a wealth of experience in litigating fraud cases in state and federal courts.

What are the penalties for a healthcare fraud conviction?

Being convicted of healthcare fraud and related crimes can result in fines, restitution, prison, probation and loss of medical licensing.

For example, making a false statement in connection with federal healthcare fraud is punishable by up to five years in prison for each offense, and being convicted of federal healthcare fraud can lead to a 10-year sentence per violation.

The monetary penalties for healthcare fraud range significantly from case to case, but a single false statement in connection with Medicare or Medicaid fraud can result in a fine of up to $250,000.

Depending the extent of the allegations, hospitals and other healthcare organizations may face millions or even billions of dollars in fines.

Contact Us

To request a consultation to discuss your case, call Hilder & Associates, P.C., at 713-234-1416 or toll free at 888-659-8742.