Government agencies or private healthcare insurance companies pay hospital bills for patients covered under their programs. Submitting or processing payments through these insurance schemes can be complex, enabling some hospitals, physicians, or patients to present or cause the intentional submission of fraudulent claims. Defrauding or attempting to defraud health insurance programs is healthcare fraud.

You should seek legal representation if arrested for this fraud crime in Northern Virginia and the City of Fairfax. With the complex payment process, you can make a genuine mistake leading to the charges. At Virginia Criminal Attorney, we will prove to the court that yours was an innocent mistake to prevent a wrongful conviction. Additionally, even when you believe you are guilty, we will defend you aggressively for a charge reduction or dismissal.

Virginia Healthcare Fraud Overview

Healthcare fraud is a general term that refers to many offenses involving the intentional deception or misrepresentation of facts by patients, physicians, or medical facilities during claims. The offense happens when medical patients or providers present fraudulent insurance claims to a government medical insurance program or private medical care insurer.

Most healthcare fraud cases involve government programs, so authorities aggressively prosecute and punish those involved. Authorities are aggressive when handling healthcare fraud cases because of the adverse impact of these cases on the healthcare system and taxpayers. Fraudulent claims overburden the healthcare system, leading to delays in accessing treatment.

Besides, when doctors perform unnecessary procedures or order unnecessary tests, they put patients at risk of suffering harm.

Similarly, fraud has increased identity theft incidents targeting private and government health insurance programs. Criminals acquire patient information and use it to acquire prescriptions unlawfully.

Also, due to fraud, companies and programs are making losses, forcing them to increase insurance premiums to enable smooth operations. Again, some insurers cut back on the healthcare benefits one should enjoy under a specific policy, increasing the cost of medical services and care.

Healthcare fraud effects are severe, and authorities relentlessly pursue those involved to ensure they face justice and discourage others from engaging in the same conduct.

With the aggressiveness of authorities, it is easy to make a genuine mistake and end up with a wrongful conviction. Therefore, your rights and freedom are better protected when you partner with a competent fraud crimes defense attorney to prove the truth and have the charges dropped.

Federal Healthcare Fraud Statutes

When you defraud or attempt to defraud a medical care insurance program like Medicare or any other plan run by the federal government, you can face fraud charges under federal statutes.

Title 18 of the US Code § 1347 criminalizes the deliberate and willful execution of fraud schemes to gain unfair financial benefits from a health insurance plan or illegally obtain money or property owned or managed by a healthcare benefit plan through pretenses, promises, or representation.

Healthcare Fraud Elements

Any fraudulent schemes against health insurance programs or the healthcare system amount to healthcare fraud. When prosecuting the case, the DA should demonstrate beyond a reasonable doubt that:

  • You knowingly and deliberately executed or tried to execute a fraud scheme
  • When you engage in the scheme, you intend to defraud a healthcare insurer or acquire property or funds controlled by a medical care benefit plan through false representation, promises, or presentation. 

The central aspect of the crime is the intent to engage in fraud. The DA should demonstrate that you plan to defraud a government health insurance plan or private health insurer. You are not guilty if the prosecutor cannot prove your motive in the alleged fraud scheme.

Knowledge is what differentiates healthcare from honest mistakes during health insurance claim presentation. When committing fraud, you should act knowingly to deceive or lie to obtain undue financial benefits. It differs from when you make a mistake or omission during a claim misconstrued as healthcare fraud. So, when the prosecutor cannot prove your actions were intentional, you can argue that you made a mistake or omission to avoid a conviction.

Healthcare Fraud Types

Healthcare fraud takes many forms, and various healthcare practitioners face the charges, including:

  • Physicians
  • Pharmacists
  • Nursing homes
  • Rehabilitation centers
  • Hospitals
  • Medical labs
  • Home infusion care providers
  • Lasting medical gear providers like prosthetics, wheelchairs, and adult diapers
  • Medical transportation firms
  • Managed healthcare entities like PPOs

The ways these parties perpetuate healthcare fraud are:

Billing or Submitting Claims for Unrendered Medical Services

A common form of insurance fraud in Virginia is billing for unrendered medical services. Medical facilities or providers commit the offense when they submit claims without evidence or documentation showing the patient benefited, such as lab tests, prescriptions, or X-rays. Also, falsely claiming medical equipment or procedures were provided when they were not amounts to billing for unrendered services.

Commonwealth of Virginia laws prohibit individuals or entities from claiming payment for medical tools, procedures, or services not rendered. You risk healthcare fraud charges and possible conviction when you cannot provide supporting documents or witnesses to testify that the medical services you seek payment for were delivered.

The prosecutor's testimony comes from patients listed on the insurance claim forms. The questions investigators ask these patients help establish if the patient visited the hospital, what medical services were offered, and the type of services provided or procedures performed. If a patient did not visit the hospital or visited but did not receive the alleged services, you will face healthcare fraud for billing for undelivered services.

Medical providers and facilities engage more in this type of fraud because patients do not understand the nature or extent of services rendered. When the services are time-based, the practitioner can delay discharge or extend treatment for undue or unfair financial benefits. Besides, a provider can render a minor procedure and claim payment for a significant procedure to obtain unwarranted financial gains.

Submitting Claims for Unnecessary Medical Tests

Another way healthcare providers engage in healthcare fraud is by misrepresenting symptoms a patient is experiencing to provide unnecessary medical tests or procedures for higher compensation. Some patients receive tests or medical procedures they do not require or for nonexistent illnesses, so the facility or provider claims extra and undue financial benefits. For instance, as a dentist, you can administer a root canal procedure for a patient who does not need it. Also, when a patient visits you with a common cold, but you seek compensation from their healthcare insurer for pneumonia, you are committing insurance fraud.

Some facilities will charge more for the same medical services or procedures if a government insurance scheme or private insurer pays for the treatment than when paying out of pocket. Others will even charge for missed medical appointments when an insurance program pays for the services, but this cannot happen when a patient pays out of pocket.

Double or Multiple Billing

You will attract charges for healthcare fraud for submitting multiple insurance claims for the same medical procedure, equipment, or service. Many hospitals or healthcare providers bill insurance companies twice or multiple times for a single procedure. The facility that engages in the practice and those who aid or abet the conduct are all engaging in fraud.

Similarly, double billing happens when a hospital receives double payment from two healthcare insurers for the same service. For instance, James is an oncologist or physician specializing in cancer treatment. He suspects one of his patients has cancer and administers multiple tests, CT scans included, and submits a claim to the patient’s insurer seeking compensation for all these tests. However, he bills the same insurer separately for CT scans, which were already included in the first claim. Under these circumstances, James is double billing and risks healthcare fraud charges.

Some cases of double billing are honest mistakes where you make more than one entry during invoice drafting. You risk healthcare fraud charges and a possible wrongful conviction even when innocent. Therefore, you will require an experienced attorney to show your actions were not intentional.

Submitting or Billing for Undercharges and Not Overcharges

The law criminalizes conspiring with other parties to claim compensation for past undercharges without submitting the same for previously overpriced medical services. Many healthcare facilities overcharge for some services but do not bill insurers. However, when they undercharge, they often submit compensation claims and omit instances where they receive overpayments.

For instance, Peter visits the hospital several times over twelve months because of a spine problem. During these visits, the physician performs several tests and prescribes drugs. However, when evaluating his records, Peter’s physician discovered instances during treatment when he overcharged and undercharged.

The first instance is when he performed some tests on Peter and prescribed medication, but when billing the insurer, he only claimed reimbursement for the tests, which were $400 but left out the drugs, which totaled $700. Under the circumstances, the physician undercharged for the medical services by $300.

In the second instance, the physician discovered that he billed the insurance company $350 for a physician’s consultation. However, he found that he had an emergency that day, and Peter saw a nurse instead of a physician. The cost of consulting with a nurse is $200. Under the circumstances, the physician overcharged the insurer by $150.

When Peter’s physician submits a claim for the $300 undercharge, he should include another for the $150 overcharge. If he only bills for the undercharge and omits the overcharge, the physician is guilty of insurance fraud.

Submitting a Deceitful or Fraudulent Claim

Submitting an untrue or fraudulent health insurance claim to acquire unfair benefits is illegal. Deceitful or untrue claims include:

  • Administering unnecessary procedures or treatments and billing an insurer for the same
  • Upcoding health insurers for more costly medical services, procedures, or equipment different from what the patient received.
  • Not charging patients with health insurance coverage the same amount as those paying out-of-pocket.

Preparing Writing or Paperwork to Support a False Claim

Preparing documents that will be utilized to back a false billing or insurance claim is unlawful.

Billing for Uncovered Medical Services

It is unlawful to charge or attempt to bill for services not covered under a healthcare benefit plan as covered. For instance, it is illegal for a doctor to submit a claim for uncovered procedures they offered, claiming they are covered under the insurance program.

For example, a physician offers a patient an experimental treatment not covered under any healthcare insurance plan by the private sector and the government. However, they still submit a claim for payment for the treatment but use a different name or service covered under the patient’s insurance plan. In this situation, the physician is guilty of healthcare fraud for billing for uncovered services as covered.

Other ways you can engage in healthcare fraud include:

  • Unnecessary prescription issuance
  • Receiving kickbacks for referrals
  • Misrepresenting a medical service provider

Agencies that Investigate Healthcare Fraud

When you are suspected of engaging in unlawful or fraudulent health insurance claims, the agencies likely to investigate the matter are:

  • The state’s medical fraud prevention unit
  • Medicaid fraud control units
  • Local medicare department
  • The Attorney General
  • The Justice Department’s strike force on healthcare fraud
  • The FBI
  • The Drug Enforcement Agency (DEA)
  • The Health and Human Services office

You will learn if any of these agencies is investigating you through:

  • A search warrant
  • A target letter from a grand jury
  • A subpoena from a grand jury
  • A civil investigative demand

You should promptly contact a fraud crimes attorney when you receive any of these notices. You must take your allegations seriously because if you are convicted, you could damage your reputation, lose your practicing license, and suffer other losses. Having an attorney early in the case means they will be with you during investigations and evidence gathering. This gives them a better understanding of the case and its circumstances. They could negotiate with the prosecutor to prevent the filing of criminal charges. If negotiations fail and you are charged, the attorney will apply their knowledge of the healthcare system, investigative skills, and understanding of healthcare fraud to prevent a conviction or charge reduction.

Similarly, an attorney will rely on their knowledge of your case’s facts to design viable defenses unique to it. They will conduct an independent investigation to find evidence the prosecutor could have missed and utilize it to poke holes in the charges.

A defense attorney will not let you enter a guilty plea even when you believe you are guilty. They will fight until the end by presenting mitigating factors that convince the court to reduce their charges or penalties.

Penalties Upon Conviction

Commonwealth Virginia severely punishes individuals convicted of healthcare fraud. The severity of your penalties depends on the value of the alleged fraud and the case’s facts. A criminal conviction will also result in a criminal record, leading to life-altering collateral consequences.

On top of the criminal charges, you risk a civil lawsuit by the health insurance program you allegedly defrauded. If the company wins the lawsuit, you must compensate them for the losses. Sometimes, the civil court can award punitive damages on top of the economic and special damages, depending on your case’s circumstances.

The legal penalties for healthcare fraud are:

  1. Prison Confinement

A guilty verdict for healthcare fraud attracts, at most, 120 months of prison confinement for every violation. If the scam resulted in injuries or loss of life, a conviction carries 120 to 240 months of prison incarceration. Based on the case’s facts, you could face grand larceny charges that attract no more than 20 years of imprisonment.

  1. Court Fines

Another penalty you could face in place of or on top of the prison confinement is monetary court fines. Upon sentencing, the court can impose financial penalties of $250,000 for every violation. When a medical institution or hospital is the defendant, the court could fine them up to $500,000 for each count. When an entity solicits or conspires to submit a fraudulent healthcare insurance claim, it faces several healthcare fraud charges depending on the methods or techniques used to accomplish the fraud. Therefore, when you, an organization, face multiple violations or counts, you risk monetary fines of millions of dollars when convicted.

Additionally, you risk charges and a possible conviction for grand larceny that is punishable by a minimum of $2,500 in financial court fines.

  1. Victim Restitution

As part of your criminal penalties, the judge can instruct you to reimburse the health insurance program or company for the money acquired fraudulently. For example, if you double-billed or billed for unrendered medical services, the court can order you to refund the funds you acquired illegally on top of the prison time and fines.

  1. Probation

When you are sentenced for healthcare fraud, the court can impose probation. Typically, you must serve a third of your sentence in prison before a parole release. The probation can last months or years, depending on your case’s facts.

Probation comes with strict conditions that you should abide by, including:

  • Avoiding crime or violation of the law during the probationary period
  • Regular meetings with your supervisor or probation officer
  • Not associating with felons
  • Maintaining employment or job

The court will drop your charges if you comply with these conditions and the probationary term lapses. However, when you violate the probationary terms, the judge revokes the program and sends you back to prison to serve the remainder of your prison time.

Legal Defenses for Healthcare Fraud

With the help of a competent fraud crimes defense attorney, you can craft viable defenses to contest the charges. The common valid defenses include:

Lack of Knowledge

During prosecution, the law requires the DA to show beyond reasonable doubt that you acted knowingly to defraud. You cannot be found guilty if you did not know your submitted claim was fraudulent or prepared a document for a false claim. In your defense, the attorney can assert that the health insurance billing system is complex and that you made a mistake during your submission. Even the best professionals in the industry make mistakes when submitting claims.

So, you can assert that you were mistaken on specific facts of the case, filled out the wrong forms, or mistakenly made a double entry, leading to your fraud charges. The argument means you did not commit the crime or know of the fraudulent claim, making you innocent. With the argument, the court will drop your charges.

You Did Not Intend to Defraud

Another defense strategy you can apply to counter your charges is arguing that you lacked the motive or intentions to commit fraud. The prosecutor must prove criminal intent to you to be guilty of healthcare fraud. The judge will find you innocent if there is no evidence to show your motive or resolve to defraud. A prosecutor must show the purpose of committing fraud. Failure to do so means the court will exonerate you. However, your attorney must explain your actions to show they lacked fraudulent intent. For instance, they can argue that your actions were accidental and that you did not mean to steal from a healthcare insurance program or company.

Constitutional Rights Breach

Investigative agencies can sometimes violate your constitutional rights during investigations. Examples of rights violations include:

  • Unlawful search and seizure
  • Forced confessions
  • Failure to recite Miranda rights
  • Arrests or traffic stops without probable evidence

When law enforcement engages in misconduct during investigations, the evidence obtained becomes illegal and, therefore, inadmissible in court. Thus, if there are instances during your arrest or investigations that your rights were violated, you can raise the issue in court and provide supporting evidence. If the court establishes your rights were contravened, they will dismiss the evidence obtained, leaving the prosecutor with a weak case. It will force the DA to offer a favorable plea deal or drop the charges.

From these defenses, you can conclude that no healthcare fraud case is hopeless. Do not assume that because all facts point at you, you are guilty. Hire an attorney to evaluate your case and find weaknesses in the prosecutor’s evidence that they can use in your favor for a charge reduction or dismissal.

Find a Fraud Crimes Defense Attorney Near Me

Charges or convictions for healthcare fraud can damage your reputation or medical career, even if the charges are false or the sentence is wrongful. Therefore, even when you believe you are innocent, you must counter the accusations aggressively with the help of an experienced fraud crimes attorney. At Virginia Criminal Attorney, we know these charges are complicated to contest when solid evidence exists against you. However, we will build solid defenses depending on the circumstances for case dismissal or lenient penalties. Contact us at 703-718-5533 to discuss your case in Northern Virginia and Fairfax, VA.