Healthcare Fraud Defense Based in Chicago

Healthcare fraud constitutes a federal crime when it is established beyond a reasonable doubt that an individual knowingly and willfully executed, or attempted to execute, a scheme to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any money or property owned by, or under the custody or control of, any healthcare benefit program. The federal healthcare fraud statute (Title 18, United States Code, Section 1347) has a broader scope compared to the federal False Claims Act. This criminal statute encompasses governmental programs such as Medicare, Medicaid, and TRICARE, in addition to private-insurance programs.

Common examples include billing for services not rendered, billing for more expensive services than those actually provided (upcoding), performing medically unnecessary services for the purpose of generating insurance payments, and knowingly submitting claims for ineligible patients or services.

Consequences can include imprisonment, significant fines, restitution (compensating a victim such as Medicare or a patient for financial losses they suffered due to a crime), forfeiture (a financial penalty intended to undo all gains from a crime), loss of medical licensure, exclusion from federal healthcare programs (like Medicare and Medicaid), and a damaged professional reputation.

Healthcare fraud is detected through various means, including audits of healthcare providers by insurance companies and government entities, whistleblower claims, data analysis of billing patterns, and tips from patients or employees. Investigations are conducted by federal and state agencies such as the Federal Bureau of Investigation, the U.S. Department of Health and Human Services’ Office of Inspector General (HHS-OIG), the U.S. Department of Labor, the Railroad Retirement Board Office of Inspector General, and state-level departments of insurance. Medicare also employs contractors to investigate and detect fraud.

If accused, individuals should immediately contact a Chicago-based attorney who specializes in healthcare fraud defense. They should refrain from speaking to investigators without legal representation. It's essential to gather and preserve all relevant documentation and follow the attorney’s advice closely.

A specialized attorney can assist by developing a comprehensive defense strategy, representing you in all legal proceedings, negotiating with prosecutors, ensuring your rights are protected throughout the investigation, evaluating your options for a trial or a plea, and working to mitigate potential penalties or seek a resolution short of trial.

Yes, with a strong defense strategy, it may be possible to have charges dropped or reduced, but this is very difficult once charges have been filed. Factors that can influence this include the strength or weakness of the evidence, procedural errors by the prosecution, cooperation with the investigation, and negotiation by your defense attorney.

Defenses may include lack of intent to commit fraud, lack of willfulness (knowledge that the conduct was illegal), and legitimate differences in medical opinion.

The statute of limitations varies based on the specific charges but typically is five years from when the crime was committed. This can be extended under certain circumstances, such as when the government alleges an ongoing conspiracy.

Just as doctors recommend regular checkups, I advise doctors to conduct periodic checkups of their practice, especially focusing on their billing practices and how they compare to their peers. Many doctors are unaware of how much Medicare and investigators can discern about their practice solely from their data. I firmly believe that there are doctors who could have avoided being charged with or convicted of serious crimes if they had been more aware of how Medicare views their claims data, particularly in areas such as home health, durable medical equipment (such as braces), prescriptions, and tests. If you do become subject to investigation or audit, it's crucial to respond appropriately and avoid exacerbating the situation. One way to turn a potential civil case into a criminal case is by altering patient files or creating fake orders.