What are the Penalties for Fraud and Abuse in Healthcare?

Since the start of COVID-19, the penalties for fraud and abuse in healthcare have gotten progressively steeper. As a result, the need for healthcare fraud attorneys has never been greater.

As you may know, healthcare fraud and abuse refers to many different crimes that involve just some of following:

• inaccurate healthcare billing
• falsifying medical records
• receiving kickbacks for referrals
• filing duplicate claims

Below, we discuss both the civil and criminal penalties for healthcare fraud and abuse at both the state and federal level.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.

Criminal Penalties for Fraud and Abuse in Healthcare

Under Michigan law, the punishment for healthcare fraud holds up to 15 years in prison and $50,000 in fines.

This is in addition to paying restitution.

Under federal law, healthcare fraud can carry up to 20 years in prison with a $100,000 fine, in addition to the repayment of wrongly obtained funds.

For both federal and state cases, a healthcare fraud charge also results in the loss of ability to bill through Medicare or Medicaid.

Healthcare fraud is investigated by law enforcement agencies such as the state police, or federal agencies such as the FBI and Inspector General.

If you’re currently under investigation for healthcare fraud, it’s extremely important to hire an attorney with experience and knowledge with this complex area of law.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.

State of Michigan Penalties

Under Michigan law, the filing of false claims, deceptive practices, and “kickbacks” for referrals is illegal.

False claims can include the following:

• overcharging for healthcare services
• charging for services that weren’t performed
• billing for medical devices that weren’t provided
• charging for unnecessary services or devices
• billing for a different service then what was provided in order to get a higher payout
• charging for the same service multiple times without providing it

Additionally, deceptive practices include entering false information into medical records and/or pretending to hold a medical license or specialty you don’t have.

A kickback is when a doctor refers patients to other doctors for treatment and receives a payment for the referral.

These include anything of value and aren’t limited to cash payments (i.e. paying for a round of golf or dinner).

Additionally, you should know that it’s illegal to pay a patient to use your services.

If you’re accused of soliciting, paying, or receiving kickbacks in connection with providing medical services, you’re facing up to 4 years in prison with a fine up to $50,000.

Also, someone who knowingly enters misleading or inaccurate information in a patient’s medical record faces up to one (1) year in jail and a $1,000 fine.

It’s also illegal to fraudulently represent that a medical device is endorsed by doctors.

If convicted, you face up to (1) year in prison and a $1,000 fine as well.

Some of the most aggressive penalties for fraud and abuse in healthcare in Michigan arise from this offense; you can’t pretend to be a licensed medical professional when you’re not.

If convicted, you face up to 15 years in prison and a $10,000 fine.

Lastly, in addition to any penalties, you’re personally liable for any payment from a healthcare insurer company that was based on false information.

If found guilty, you’ll owe restitution in the full amount.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.

Federal Penalties

Typically, federal authorities focus on Medicare fraud.

Any billing for medical services or products that aren’t necessary or accurate will result in criminal charges.

It’s illegal to knowingly present a false claim for payment to a federal agency, such as Medicare.

Anyone who executes (or tries to execute) a scheme to defraud Medicare faces 10 years in prison and a fine up to $20,000.

If convicted of seriously injuring someone as part of the fraud, you face 20 years in prison. (18 USC 1347).

Like Michigan law, federal law also prohibits the payment to induce or reward patient referrals for any service paid for by a federal healthcare program.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.

Civil Penalties for Fraud and Abuse in Healthcare

Civil penalties for federal healthcare fraud are also severe.

If you’re convicted of receiving kickback(s), you’re subject to civil penalties of up to $50,000 per kickback. (42 USC 1320).

Someone convicted of making a false claim is personally liable for 3x the amount of the payment received, in addition to $11,000 per false claim filed.

It’s also illegal to conceal or falsify assets to qualify for federal medical assistance.

If found guilty, you face 10 years in prison and $100,000 fine.

Similarly, it’s illegal to counsel or assist someone in doing so.

Someone convicted of this faces one (1) year in prison and $20,000 fine.

Lastly, making false statements about the condition or operations of a medical facility to make it eligible to receive federal funds is a felony.

This offense carries up to 10 years in prison and $100,000 fine.

This is just a short list of the potential crimes and penalties associated with healthcare fraud.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.

Possible Defenses for Healthcare Fraud and Abuse

We know that an allegation or charge doesn’t mean you’re guilty.

Consider some possible defenses.

Was the alleged fraud accidental?

During the investigation, you may be able to correct a mistake in billing that wasn’t intentional as a defense to the charge.

Especially if this is an isolated occurrence as opposed to a pattern.

Additionally, medical necessity can be a defense.

Since medical treatment is often subjective, you may be able to argue that what appears to be excessive billing is actually medically necessary.

This can be properly defended based on the patient’s condition, or if duplicate treatment was necessary for the particular patient.

Also, what looks like a kickback may very well have an innocent explanation.

Is there a reason aside from the referral of patients that explains a benefit given to you by another medical provider, such as prior loans or agreements?

Good faith can also be a defense.

At the time you submitted a bill or entered information into a medical record, what’s believed to be correct based on the information available to you?

As you can see, the defenses for healthcare fraud are extremely complex.

This is why you need to hire a healthcare fraud attorney as soon as possible if you suspect or know you’re under investigation for healthcare fraud.

They’ll expertly defend you, and are your best chance to avoid prison time, high fines and losing your professional license.

Whoever you hire, your attorney should know both state and federal compliance issues and investigation techniques.

Additionally, your lawyer should differentiate between mistakes and intentional crimes while raising all possible legal defenses.

Should I Hire a Healthcare Fraud Attorney Now?

The penalties for fraud and abuse in healthcare fraud include significant prison time and exorbitant fines.

If you’re facing criminal charges for healthcare fraud, you need an experienced and proven federal attorney by your side.

Due to the potential criminal and civil penalties, you must act now to avoid jail time and protect your financial assets.

Our team of expert criminal defense attorneys can, and will, assist you during the investigation and litigation phases of your case.

Don’t wait until charged to find an attorney; start the process now before it’s too late.

Under investigation or charged with healthcare fraud? Unhappy with your current attorney? Request a free consultation now.