What Are the Most Common Types of Healthcare Fraud?
Unfortunately, healthcare fraud remains prevalent in Texas and the United States, costing taxpayers and patients millions. Texas has stringent laws against these dishonest practices, encompassing state and federal statute violations. But what exactly constitutes healthcare fraud?
It refers to illegally obtaining money or benefits from government healthcare programs like Medicare and Medicaid or private health insurance companies. Healthcare fraud involves everything from overbilling services to prescribing unnecessary medical equipment in return for personal profits.
Common Forms of Healthcare Fraud in Texas
Some of the most typical deceitful schemes include:
- Billing for Services Not Performed: This type of healthcare fraud occurs when a provider bills patients or insurance companies for medical services, tests, or procedures that were never actually done. For example, a physician might bill for an office visit that didn’t happen.
- Upcoding: Here, providers bill for more expensive services than were provided. For instance, a practitioner may bill a routine appointment as a more complex “level 4” visit.
- Kickbacks: Kickbacks involve healthcare businesses paying one another illegal bribes to receive patient referrals. This fraud drives up costs for private insurers and government programs.
- Prescription Fraud: Doctors or pharmacists bill insurers for brand-name medications but provide patients with cheaper generics instead, pocketing the difference.
- Identity Theft: Criminals steal patient information to falsely bill for medical services or equipment under the patient’s name.
Healthcare Providers That Commit Fraud
Many different players in the medical industry commit healthcare fraud, including:
- Doctors: Physicians sometimes order excessive tests or procedures to drive up costs or make referrals for their own financial gain.
- Clinics and Hospitals: Medical centers bill for phantom services, upcode visits, and procedures or fabricate patient records for reimbursement.
- Pharmacies: Besides prescription scams, some pharmacies bill government programs or insurers for more expensive medications than they buy and dispense.
- Medical Equipment Companies: Equipment providers scam insurers by using aggressive marketing to provide unnecessary wheelchairs, braces, or other medical devices.
How Texas Authorities Investigate and Charge Healthcare Fraud
In Texas, both state and federal agencies rigorously investigate healthcare scams, including:
- Medicaid Fraud Control Unit: The Texas Attorney General’s office division prosecutes cases involving overbilling or kickbacks in Medicaid or Medicare. Charges can include Medicaid fraud, insurance fraud, or other violations.
- Office of Inspector General: The federal OIG audits Medicare billing and conducts investigations, often coordinating with the Medicaid Fraud Control Unit. They can seek civil monetary penalties or exclusion from federal healthcare programs.
- Texas Penal Code: State law also allows charges under the penal code for felony or misdemeanor healthcare fraud when the accused uses deceit to obtain benefits unlawfully.
Defending Against Healthcare Fraud Charges
An aggressive legal defense is critical when facing healthcare fraud charges, which can result in heavy civil fines or even prison time. Texas criminal defense strategies may include:
- Challenging Evidence: Often, fraud investigations rely heavily on medical coding and billing records. Picking apart this financial evidence and revealing flaws in the prosecution’s case is necessary.
- Demonstrating Good Faith: Even if billing procedures violated rules, showing that the provider acted in good faith and without criminal intent can help achieve a better outcome.
- Seeking Reduced Penalties: An experienced criminal defense healthcare fraud attorney can negotiate with prosecutors to minimize penalties, especially for first-time offenders who self-report errors.
- Avoiding Licensure Sanctions: Beyond fines and jail time, a conviction can threaten a medical professional’s license. An excess criminal defense lawyer can help develop arguments focused on enabling continued practice.
Working with a Texas Healthcare Fraud Defense Lawyer
Facing civil or criminal fraud charges can be overwhelming. An attorney experienced in this highly complex field can help protect your rights and career.
Be sure to seek counsel from a healthcare fraud lawyer who:
- Focuses on Healthcare Law: Handling these intricate cases requires in-depth knowledge of rules governing federal programs, private insurance, billing protocols, and more.
- Has Trial Experience: While you should expect your attorney to negotiate settlements, a seasoned litigator is fearless in taking your case to trial if it’s in your best interest.
- Provides Client-Focused Counsel: More than just an aggressive courtroom defender, the right lawyer will offer clear legal advice and vigorously safeguard your interests at every phase.
Defending against healthcare fraud allegations requires a refined legal strategy. Whalen Law Office can help Texas medical professionals, clinics, and hospitals navigate this challenging territory.
Contact their Texas healthcare fraud defense attorneys online or call to schedule your case evaluation.
