Title 18 U.S.C. §1347 makes it a federal offense to commit health care fraud. The prosecution of health care fraud allegations focuses on whether the medical provider knowingly defrauded a health care benefit program by submitting claims for services or products that were never provided or rendered services that were not medically necessary.
Oftentimes, federal and state agencies act jointly to ferret out fraudulently submitted claims by investigating and auditing doctors, ambulance companies, pharmacists, hospitals, clinics and other providers who are doing business with health care insurers. Many health care fraud allegations relate to the government programs of Medicare (federal) and Medicaid (state).
Administrative Audits Of Health Care Providers
Criminal prosecutions may blossom from an administrative audit of the provider. For example, a Medicare auditor may look closely at a sample of patients and determine that their billed treatment was not medically necessary. An unsuccessful review could trigger a further inquiry, an appeal process, suspension of the provider’s Medicare or Medicaid number, reimbursement for loss or even criminal prosecution.
A provider receiving an audit letter or who is indicted for health care fraud should immediately consult with counsel adept at investigating and advising medical providers. A successful administrative review could remove the provider from the government’s radar, thus it is critical to follow the administrative process.
If indicted for and convicted healthcare fraud, a person can face severe penalties under the sentencing guidelines because the loss associated with medical claims is often steep. Thus, prosecutors may seek tens of millions in damages, years in prison and forfeiture of assets. If you’ve been accused of health care fraud in Texas, our Houston-based healthcare fraud lawyers are ready to fight for you.
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