Potential Civil and Criminal Outcomes of Medicare and Medicaid Fraud Charges

The term white collar crimes refers to a category of crime that is typically nonviolent and includes fraud or corruption of some type. General healthcare and prescription drug fraud both fall into this category, as do Medicare and Medicaid fraud.

The federal and state governments take these types of crimes very seriously. They publish numerous resources to encourage providers and workers in the medical field to prevent, detect, and report potential issues of fraud.

Unfortunately, many healthcare organizations are large, and each department or team member doesn’t always know what the other is doing. What if someone else in your organization is committing fraud — knowingly or unknowingly — and you get caught up in the issue? What consequences might you face if you are charged with Medicare or Medicaid fraud?

What Is Healthcare Fraud?

Healthcare fraud can occur in a number of ways. One of the most obvious is submitting false claims. Both New Jersey and the federal government have specific laws against this. Healthcare providers cannot submit claims to Medicare, Medicaid, or other health insurance payers for any services or items that weren’t provided to the patient or received by the patient.

For example, say a mail-order pharmacy ships out durable medical equipment to a patient. If the patient doesn’t receive the equipment, the pharmacy technically can’t bill for it even though it attempted to provide it.

Other types of healthcare fraud include:

  • Participating in kickback schemes. Doctors and others in the medical industry cannot offer any type of value in kind for referrals. For example, a doctor can’t offer $50 off of services to patients who refer others, and a pharmaceutical company cannot provide an all-expense paid vacation to the physician who prescribes its product most.
  • Self-referrals. Federal law prohibits doctors from referring patients to other clinics or service providers if the doctor or one of their family members has a financial interest in that other business — unless there is a specific lawful exception.

What Are the Consequences for Healthcare Fraud?

Being charged with or convicted of healthcare fraud involves numerous potential consequences. Those consequences can impact your career, personal financial stability, family, and freedom.

Professional Consequences

Being charged with healthcare fraud — even if you aren’t convicted — can negatively impact your career. Depending on how your case is handled, it can result in public relations issues and may reduce the trust other medical providers and patients have in you. Working to demonstrate your innocence can be as much about clearing your professional name as it is about safeguarding your personal freedom.

If you are convicted, you can face further professional consequences. You may face suspension or revocation of any professional licenses you hold. The Office of the Inspector General is also required to exclude you from federal healthcare programs if you have ever been convicted of Medicare or Medicaid fraud. This means you would not be able to participate as a provider in Medicare, Medicaid, Tricare, or other federal payer programs, limiting your patient and revenue streams.

Other Civil Consequences

A conviction of Medicare or Medicaid fraud can result in stiff financial penalties for individual providers or organizations. For example, the federal government authorizes various Health and Human Services agencies to seek civil monetary penalty payments. States also have laws that allow civil penalty payments in such cases.

To understand how much you might be on the hook for in cases of healthcare fraud, here are some examples of HHS civil monetary penalties:

  • Penalty for billing for outpatient services knowingly without assignment: up to $17,472 per instance
  • Penalty for a doctor who charges a non-participating referral more than 125%: up to $17,472 per instance
  • Penalty for offering any kind of kickback to attempt to persuade Medicare or Medicaid beneficiaries to use particular providers, services, or products: up to $22,427 per instance

These are just a few of the many detailed federal fees related to healthcare fraud. Aggregate fees in cases can reach as high as millions of dollars — enough to bankrupt an individual or practice.

Potential Criminal Consequences

Medicare and Medicaid fraud can also come with criminal consequences, including multiple years in prison. The length of sentence you might face depends on factors including the type of fraud charges you’re facing and how many counts of each charge you are facing. See N.J.S.A. 2C:21-4.3(b) (Health Care Fraud) and N.J.S.A. 30:4D-17(b) (Medicaid Fraud).

What Should You Do if You Discover a Potential Issue?

Potential fraud in your organization is not something to be swept under the rug or ignored. Doing so can make you potentially complicit and create a situation where you might face some or all of the above-discussed consequences.

If you discover that you or your organization may have misfiled claims and received payment for services that weren’t rendered, it’s important to correct the issue as soon as possible. Talk to your internal compliance department and to a lawyer experienced in healthcare fraud cases to create a plan, which likely needs to include setting the records straight and refunding monies.

Get Legal Help as Soon as Possible

If you are facing Medicare or Medicaid fraud charges or have reason to suspect you might face such charges soon, getting ahead of the situation can help. The sooner you proactively work on a defense, the better chance you may have at a more positive outcome.

Contact the Bianchi Law Group at 862-210-8570 to discuss how we can help with your case.