Officials throughout the country continue to crackdown on potential healthcare fraud cases. The primary motivator is one of the oldest and strongest: money. The feds get billions back from healthcare fraud cases every year.
How do these cases work?
The government is either notified of a potential healthcare fraud case through a whistleblower, or someone with inside information that tips them off, or if software picks up concerning claims. Once an investigation begins, the government will review various pieces of evidence to determine if the claims are fraudulent or legit.
In a recent example, Texas officials charged 11 with health care fraud crimes. The allegations resulted from an investigation that led to evidence of a potential kickback conspiracy. The charged included two physicians, a nurse practitioner and marketing employees, lab personnel. The government claims that lab personnel would use marketers to contact medical professionals. The lab personnel would allegedly enter agreements to provide payment to the physicians in exchange for lab tests. The more tests they ordered, the higher their payment.
The government argues the claims for payment to Medicare were not legitimate because they were not medically necessary. Since payment resulted from claims to Medicare, the allegations led to charges of a False Claims Act (FCA) violation.
When faced with the evidence, the accused accepted plea deals. The physicians and nurse practitioner face up to five years imprisonment for conspiracy to solicit and receive illegal kickbacks. The owner of the marketing firm faces up to 15 years imprisonment for conspiracy to pay kickbacks.
Some will accept plea deals in these types of cases, others will fight the matter through traditional litigation. The best path will vary depending on the details of the allegations and available evidence.
Attorney John Rivas is responsible for this communication