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Understanding Federal Healthcare Fraud

Posted on in Criminal Defense

Wisconsin criminal defense attorney, Wisconsin defense lawyer, federal crimesThe healthcare sector of the economy is a multi-billion dollar industry that is growing rapidly as a result of scientific advancements and an aging population. On top of this massive growth, the government has laid down complex regulatory and benefits systems over the industry. This combination of large amounts of money and bureaucracy has led some people to develop a new type of crime: healthcare fraud. The general idea behind healthcare fraud is that healthcare providers lie to the government about something in an effort to get paid more than they deserve, but that description does not do justice to the wide array of different things that qualify as healthcare fraud.

Types of Healthcare Fraud

The federal statute on healthcare fraud criminalizes a wide variety of conduct. Someone commits healthcare fraud when they either knowingly attempt to “defraud any healthcare benefit program,” or when they lie in order to get money from a healthcare benefit program. With such broad definitions, many things fall under the law's scope.

One of the most straightforward types of this fraud occurs when a petitioner bills for a service that they never provided. Similarly illegal is billing for the same service twice, or billing for a more expensive service than the one actually performed. The schemes can get much more complex though.

For instance, providers can fraudulently abuse the diagnosis-related group (DRG) system. DRGs are classifications for different diagnoses that hospitals can place patients in based on the types of disease that they have. Different DRGs get different payment amounts from healthcare benefits programs, so knowingly applying the wrong DRG code can be grounds for a fraud case.

Penalties for Healthcare Fraud

There are a variety of penalties for the crime of healthcare fraud. The most straightforward penalties are the fines and jail time under the statute. The law allows judges to impose a sentence of up to 10 years for healthcare fraud along with a fine of up to $250,000. That fine can also be increased to up to $500,000 in the case of organizations. Additionally, if the fraud results in serious harm or death to a person, then the sentence can be increased to 20 years or life respectively.

There are also civil remedies for healthcare fraud. The False Claims Act allows whistle-blowing employees to sue for damages on behalf of the government. If they win, then they receive a portion of the damages. This civil remedy can be especially damaging because the government may be able to collect three times the amount of the initial fraud, in addition to civil fines.

Although healthcare fraud is a white collar crime, the penalties can be severe. If you have recently been accused of healthcare fraud, contact an experienced Milwaukee criminal defense attorney today to learn more about your rights.

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