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Can I go to prison for healthcare fraud?

Physicians, nurses, and other healthcare professionals must follow various federal regulations. A failure to do so can result in serious penalties, including civil fines, the failure to get reimbursement from federal healthcare programs like Medicare and the loss of your license from the state medical board.

Depending on the details of the violation, it can even lead to prison time.

In a recent example, the Department of Justice (DOJ) went after a 63-year-old physician, claiming he was part of a healthcare fraud scheme that led to over $38 million in fraudulent claims. The government states the physician prescribed Infliximab, an immunosuppressive medication used for treating Crohn’s disease, colitis, rheumatoid and psoriatic arthritis along with other ailments, too frequently. They argued that the physician often prescribed the expensive medication without medical necessity. They were able to gather enough evidence to convince a U.S. District Judge to an aggressive sentence of 60 months imprisonment as well as the forfeiture of various properties and additional monetary penalties.

Federal regulations allow the government to pursue such sentences. The three federal regulations that agencies most often use against medical professionals include the following.

#1: The False Claims Act (FCA)

The government can pursue violations of the FCA as a civil or criminal matter. When it comes to criminal FCA violations, the government can send physicians to prison for submission of false claims to government programs, often accusing the physician of filing claims for services or medications that are not medically necessary. Examples of government programs include Medicare and Medicaid.

#2: Anti-Kickback Statute (AKS)

This law makes it illegal to pay remuneration in exchange for patient referrals. The government has pursued cases that include lavish meals or bonuses for speeches and courses that were never actually provided. The government can potentially go after both those making and receiving remuneration for a violation of the AKS.

#3: The Stark Law

Also known as the Physician Self-Referral Law, a violation of the Stark Law occurs when a physician makes a patient reference to a facility where there is a financial connection either to themselves or a family member.

Attorney John Rivas is responsible for this communication