Houston is a major hub for the nation’s Medicare fraud prosecutions. Last year the Houston Chronicle quoted the city’s U.S. Attorney, Ken Magidson, as saying:
“[Medicare fraud] is an important battle. The people who commit these crimes are not just defrauding the government out of hundreds of millions of dollars. They are attacking our entire health care system.”
There nine hubs for a Medicare Fraud Strike Force—Houston is one of them.
Recently a 53-year-old Houston woman was sentenced to 75 years in prison for a $13 million Medicare fraud scheme.
Marie Neba of Sugarland, Texas, co-owned Fiango Home Healthcare with her husband and served as the nursing director.
According to court records, she was convicted for paying kickbacks to patient recruiters who referred Medicare beneficiaries to her agency. She used millions of dollars in proceeds from fraudulent Medicare claims to pay the recruiters. Four others have entered guilty pleas and are facing federal charges of taking and giving kickbacks, committing health care fraud, and conspiracy.
When Do Federal Health Care Laws Come Into Play?
Federal health care laws apply when a person attempts to defraud any health care benefits program with the intent of gaining property or money. Each state has its own health care laws, but the federal law applies in all states whether state law punishes the fraud or not.
Health care fraud can occur with both private insurers and the two public health insurers, Medicare and Medicaid. Both public insurers are frequent targets of false claims. Federal laws that target those who make false claims include instances of healthcare fraud, making false statements, kickbacks, and other related activity.
Up to 10 percent of all money spent on health care each year is paid on fraudulent claims. The false claims can be made by patients, insurers, and health care providers and the claims can come in many different forms.
On the patient side, fraud schemes include stealing someone’s identity to receive health care services, making false claims, and faking illness to receive prescription medication to sell.
On the provider side, the most common form of health care fraud occurs when a provider attempts to get more money from insurers by making duplicate claims for the same service.
Another method is filing a claim for a service that never occurred. A health care provider may bill for services that aren’t covered by insurance. Others, like Neba, may give kickbacks for patient referrals.
The anti-kickback federal law keeps anyone from intentionally receiving, paying, soliciting, or offering remuneration to induce or reward business referrals for Medicare or Medicaid. Safe harbors exist as an exception to this law. Providers may furnish software or information technology to a referral source, such as between a hospital and a physician’s private practice. The electronic health records safe harbor protects some situations which involve software and/or information technology.
It’s wise to seek legal counsel on safe harbor measures to understand your rights.
What It Takes to Get Convicted of Health Care Fraud – and What Penalties You Face
What is the difference between health care fraud and an honest mistake?
It boils down to intent. Double-billing and incorrect claims occur as mistakes. However, fraudulent claims require an intent to provide false information with the goal of financial gain. An example of this would be a doctor ordering unnecessary tests for a patient, then benefiting from the insurance claims on the tests.
If you are convicted of health care fraud, you may face both civil and criminal charges. A conviction in civil court would result in a fine paid for restitution. A conviction in criminal court can result in restitution fines, prison time, and additional fines. Here is a breakdown of the penalties for criminal convictions.
False claims or statements related to Medicaid or Medicare can result in five years in prison for each offense. If you are convicted for federal health care fraud, you may face 10 years in prison for each offense. The sentence can be increased to 20 years in prison if the offense results in serious bodily injury and life in prison if someone dies.
Steep fines will apply for these charges as well. Individuals making false claims or statements in Medicaid or Medicare can face up to $250,000 per offense. If an organization makes the same false claims or statements, they may face up to $500,000 per offense. Organizations with multiple counts of health care fraud in ongoing schemes can face many millions of dollars in fines. These fines are paid to the government.
Restitution may be part of the sentencing as well. Restitution is paid back to the individual or organization affected by the fraud. For example, a patient who made false claims to get prescription medication to sell may be ordered to pay back the money allocated by the insurance company for the medication.
Do Not Try to Tackle Complicated Federal Health Care Fraud Charges Alone
If you have been charged with health care fraud, it’s essential that you contact an experienced attorney as soon as possible. Your attorney will work to build a strong defense against the charges and prepare you for federal investigations. Contact a knowledgeable criminal attorney