Healthcare Fraud

Health care is one of the largest parts of the American economy, with estimates of over $2.27 trillion spent every year. Fraud in the healthcare field is estimated to range from $100 billion to over $230 billion. Many healthcare fraud cases end up in federal court. Some people and companies are guilty of healthcare fraud, but not all of them. Just because some federal prosecutor claims that a person or company committed healthcare fraud does not mean it really happened. Anyone facing one of these cases needs an experienced criminal defense attorney to help him or her through this harrowing process. Paul Kish is an Atlanta Federal Criminal Defense Lawyer who has handled many such cases over the past 36 years.

Healthcare fraud comes in a wide variety of fact patterns. Sometimes, prosecutors claim that the company billed for services that were never provided by using genuine patient information, often obtained through identity theft. Other times a real patient was seen, but the office padded the claims with procedures that never were provided. Other cases involve what is called “upcoding,” which means submitting a bill for a more highly priced treatment than what was actually provided to the patient. This process often involves changes to the “procedure codes” which are the heart of healthcare billing. Other healthcare frauds involve services that are not truly necessary for the patient, so as to generate large payments to the provider. Other times, these cases involve treatments that are not normally covered by insurance, but the clinic falsely claims that the treatment is a “medical necessary”. There have also been situations in which a medical provider falsified the patient’s diagnosis in order to justify expensive tests and procedures that are not truly medically necessary. Also, “kickbacks”, the process of paying for referring patients or procedures, is another form of healthcare fraud.

Most of these cases are handled in the federal court system. The main reason is because the vast majority of health care dollars can be traced back to either Medicare, Medicaid or some form of insurance that is offered by companies operating in interstate commerce (which gives a federal prosecutor the jurisdiction to bring the case into federal court). While most healthcare fraud matters are in federal court, more and more states have started their own task forces to handle such matters on the local level. These Medicaid Fraud Control Units (MFCU’s) operate in almost every state and are generally part of the State’s Attorney General’s office. While the State MFCU sometimes operates independently, often its lawyers, investigators and accountants work in conjunction with their federal counterparts. Therefore, an attorney handling the defense of a federal or state healthcare fraud case needs to be accustomed to working with both the state and federal prosecutors and investigators. Although Paul is a criminal defense attorney in Atlanta, he has handled cases from state MFCU’s across a wide geographic area,

In 18 U.S.C. § 1347 Congress created a basic health care fraud statute to be used in federal court. This law makes it illegal to make a false statement or promise to defraud a health care program, and covers fraud involving both government sponsored health care programs and private insurance companies. This law has a penalty of up to 10 years in prison, which is lower than the maximum sentences for other types of federal fraud. However, the federal sentencing guidelines generally are the most important rules for determining a sentence in any federal fraud matter. Congress also created a separate special conspiracy law for healthcare fraud matters, 18 U.S.C. §1349. It also has the same 10-year maximum penalty but covers larger groups of people and sounds more ominous. The worst thing about the healthcare conspiracy law is that it allows a federal prosecutor to throw a group of otherwise disconnected people together in the same indictment and let them fight it out by pointing the finger at one another.

Defending against a healthcare fraud allegation should only be handled by an attorney highly experienced in such cases. Sometimes, the lawyer will defend the case by showing that the accused person did not intend to commit fraud, even if some of the billing was not performed correctly. Other times, the best defense is to go on the offense: to point out that the agents and investigators violated rules or constitutional protections when obtaining evidence. In just about any healthcare fraud case, the defense team often needs experts to asses and analyze the mountains of evidence that such cases generate. Paul Kish is an experienced Atlanta Federal Criminal Defense Lawyer who handles these cases and who relies on retired federal agents and forensic accountants to check and then take apart the evidence accumulated by the prosecution team. Sometimes the defense needs to hire its own medical doctor or other specialist to show that the accused person or company did its job correctly.

Healthcare fraud cases are exceedingly complex and are becoming more and more common. If you or a loved one is faced with such a criminal prosecution, call Paul Kish. He is an Atlanta federal criminal defense lawyer who has 36 years of experience in these cases.