Facing Medicare or Medicaid fraud charges in Texas can be overwhelming and carry severe consequences, including substantial fines, federal penalties, and possible jail time. These cases often involve allegations such as billing for services never provided, upcoding, ordering medically unnecessary tests or treatments, participating in kickback schemes, or improper use of patient information to submit fraudulent claims. Even billing errors or documentation issues can quickly escalate into criminal investigations when authorities believe a pattern exists.
At Hilder & Associates, P.C., we understand how aggressively these cases are pursued. Our experienced legal team works to identify the specific allegations involved, examine billing and medical records, and protect your rights during federal or state investigations. By carefully analyzing the evidence and challenging inaccuracies, we help clients defend their reputations, livelihoods, and futures at every stage of the process.
Types of Medicare and Medicaid Fraud
Medicare and Medicaid fraud charges in Texas can be difficult to navigate, especially if you are suddenly caught in the middle of a federal investigation. These programs involve massive amounts of government funding, and authorities take potential misuse very seriously. Always recognize the serious nature of these charges and why immediate defense representation is essential.
Billing for Services Not Provided
One of the most frequent allegations involves billing for services that were never provided. This occurs when healthcare providers or billing staff submit claims to Medicare or Medicaid for appointments that never happened, procedures that were never performed, or tests that were never conducted. Even if these discrepancies result from billing errors or administrative mistakes rather than intentional fraud, prosecutors may pursue criminal charges when patterns suggest systematic overbilling.
Upcoding
Upcoding means billing Medicare or Medicaid for a more expensive service, procedure, or level of care than what was actually delivered to the patient. Medical billing uses specific codes that correspond to different services and complexity levels. When providers consistently bill using codes for more intensive or complex services than they actually provided, it raises red flags with fraud investigators. While some upcoding results from coding errors or misunderstandings of proper billing practices, federal prosecutors often interpret patterns of upcoding as intentional fraud designed to increase reimbursements.
Billing for Medically Unnecessary Services
Investigators scrutinize situations where providers order excessive tests, treatments, procedures, or prescriptions that don’t match a patient’s actual medical needs. This type of fraud allegation arises when healthcare providers order services primarily to generate billing revenue rather than to address legitimate medical conditions. These charges can be particularly complex because they involve medical judgment calls about what constitutes appropriate care, requiring expert testimony to establish whether services were medically justified.
Kickback Schemes
Kickback schemes involve healthcare providers, suppliers, or others receiving payments, gifts, or other benefits in exchange for patient referrals or the use of certain medical services, equipment, or facilities. The federal Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals for services covered by federal healthcare programs. These arrangements can take many forms including cash payments for referrals, free rent or equipment provided to referring physicians, inflated consulting fees that serve as disguised referral payments, or lavish gifts and entertainment provided to influence referral decisions.
Identity Theft and Improper Use of Patient Information
You could face charges related to improper use of patient information, such as using stolen or purchased Medicare or Medicaid numbers to submit fraudulent claims. This type of fraud involves obtaining patients’ personal information and government healthcare identification numbers without authorization, then using that information to bill for services those patients never received. Identity theft in healthcare fraud can occur when employees steal patient information from medical facilities, criminals purchase patient data from black markets, or providers use deceased patients’ information to continue billing for services.
Phantom Billing
Phantom billing involves submitting claims for equipment, supplies, or services using the names and identification numbers of patients who have no relationship with the billing provider. This fraud often involves billing Medicare or Medicaid for durable medical equipment like wheelchairs, oxygen equipment, or diabetic testing supplies that were never ordered, delivered, or needed by the patients whose information appears on the claims.
Duplicate Billing
Duplicate billing occurs when providers submit multiple claims for the same service, procedure, or supply. While some duplicate billing results from administrative errors, systematic duplicate billing that generates repeated payments for single services constitutes fraud. Investigators identify this fraud by examining billing records for identical or nearly identical claims submitted for the same patient on the same dates.
Unbundling
Unbundling involves billing separately for procedures or services that should be billed together as a package at a lower combined rate. Medical billing includes “bundled” codes that cover multiple related procedures performed together. When providers instead bill each component separately using individual codes that generate higher total reimbursement, they commit unbundling fraud. This practice artificially inflates what Medicare or Medicaid pays for services.
Each of these allegations can bring significant penalties, including substantial fines, exclusion from participating in federal healthcare programs, restitution obligations, and possible imprisonment. The severity of potential consequences makes awareness of these issues essential and underscores why anyone facing Medicare or Medicaid fraud allegations needs immediate legal representation from attorneys experienced in federal healthcare fraud defense.
Defenses You May Raise to a Medicare or Medicaid Fraud Charge
If you are facing Medicare or Medicaid fraud charges in Texas, you may feel like the situation is already stacked against you. However, you should know that several legal defenses may be available to challenge the allegations. These defenses focus on your intent, the accuracy of the government’s evidence, and the possibility of misunderstandings within complex billing systems.
- One of the strongest points you can raise is the lack of intent. To convict you, prosecutors must usually prove that you knowingly and willfully committed fraud. If the billing error was accidental, the result of confusing coding rules, or caused by a clerical mistake, that lack of intent can be a powerful defense.
- You may also challenge the charges by questioning the accuracy and reliability of the government’s evidence. Medicare and Medicaid billing systems are enormous, and investigators sometimes rely on algorithms or audits that misinterpret legitimate claims. If their data is incomplete, misleading, or taken out of context, you can use that to your advantage.
- Another possible defense involves showing that you relied on professional guidance, such as billing specialists or software systems, and reasonably believed the claims complied with program rules. In a system as complicated as federal healthcare billing, this can help demonstrate that any errors were unintentional.
- Finally, you can argue that the alleged conduct does not actually violate the program’s rules. Regulations frequently change, and what investigators assume is improper may be permitted under current guidelines. By highlighting these uncertainties, you can create real doubt about the charges you are facing.
Talk with Our Experienced Medicare and Medicaid Fraud Defense Attorneys Today
At Hilder & Associates, P.C., we represent clients at every stage of Medicare and Medicaid fraud investigations and criminal proceedings. For a case evaluation with a knowledgeable Medicare and Medicaid fraud defense lawyer, please call our office at (713) 234-1416 or contact us online today.
