What constitutes healthcare fraud? And what should the accused do first?

The federal government is increasingly aggressive about prosecuting fraud and eliminating waste in the healthcare industry. Additionally, insurance companies have their guard up, and whistleblower suits are on the rise.

While many fraudulent healthcare schemes are rudimentary — for example, using patients’ identities to bill Medicare, Medicaid and insurers for services never provided — other schemes are more sophisticated.

If you have been accused of — or are suspected of — healthcare fraud of any kind, you should immediately seek legal counsel from a white collar crime defense lawyer — someone with extensive legal resources and experience in state and federal cases.

What must the government prove to get a healthcare fraud conviction?

Generally, for you to be convicted of healthcare fraud, the government must prove that you knowingly engaged in activity to provide false information in order to achieve financial gain.

Keep in mind, though, that health insurance and billing involve complicated requirements and restrictions, and innocent mistakes are common. The mere fact of an improper payment, omission or mistake does not necessarily mean that fraud had been committed.

What should an investigated or accused individual do?

If you have received notice of an audit, or if law enforcement officials have raided your office, the importance of reaching out for legal counsel cannot be overstated.

In some cases, doctors and other medical providers are able to avoid prosecution after a skilled defense team conducts an internal investigation to ensure that administrative processes are followed. Actions taken with legal counsel prior to the filing of any fraud charges can be critical in mitigating any negative consequences.

The government and insurers are on the lookout for these and other types of healthcare fraud:

  • Filing claims for services not rendered
  • Self-referrals
  • Paying kickbacks for referrals
  • Double-billing for the same service
  • Billing for phantom patients
  • Billing for services not covered by the policy
  • Intentionally providing unnecessary medical services and then billing for them

Multiple errors in billing can trigger an investigation, and Texas is a leading state for whistleblowers and prosecution of healthcare fraud. For more on these matters, please see our Medicare and Medicaid fraud overview, as well as our general healthcare fraud overview.