Healthcare providers are highly trained professionals whose knowledge and skill allows them to make lifesaving decisions on behalf of their patients. Doctors and skilled surgeons must have the best interests of their patients in mind when deciding on the best procedures, medications, or treatments for them.
For a medical professional in New York City or Long Island who becomes the target of a qui tam civil action or even criminal charges for healthcare fraud, this could not only destroy their reputation but also result in costly and crippling legal expenses, fines, or even jail time. An error in medical coding, incorrect bundling charges, or a wrong referral could lead to a whistleblower charge against them. Having the appropriate legal protection at this time is essential to building a strong and effective defense against charges.
How does a medical fraud case begin?
Many healthcare fraud claims begin over miscommunication of services rendered, leading to:
- Incorrect or duplicate billing for services.
- Incorrect dates or provider of services.
- Phantom billing for tests, medical devices to a nonexistent patient.
- Unbundling tests and procedures to increase reimbursement.
- Lack of medical necessity.
- Incorrect or false research data when securing a grant.
- Fraudulent referrals in Medicare and Medicaid billing.
Under the federal statute, 31 U.S.C. §§ 3729-3733, also called the False Claims Act (FCA), a private citizen may file a claim on behalf of the government as a qui tam claim in civil court for violations of the FCA. The whistleblower who brings a qui tam is called a relator, and they are entitled to receive 15% to 20% of the recoverable award by the government. The motivation of a whistleblower in a qui tam action may always be subject to scrutiny, as they stand to receive financial profit from a conviction.
For the suit to move forward, the accused must have violated the terms of the FCA by knowingly submitting false claims or making a false statement or record, in order to receive money illegally or to avoid making payments to the government.
Although many healthcare fraud cases begin in civil court, they often turn into criminal cases. Federal false claims civil penalties include reimbursement for attorney’s fees and up to triple the government’s reimbursement. Under separate criminal statutes, violation of the FCA is a felony and punishable by up to ten years in prison on each charge, including possible revocation of their medical license.
What are the best defenses for a healthcare fraud claim?
Conviction on FCA charges hinges on the healthcare provider’s knowledge of and complicity in the fraud, and that they had:
- Actual knowledge.
- Deliberate ignorance of the verity or falsity of the information.
- Reckless disregard.
If the government is convinced that the individual is liable under the provisions of the FCA, the case will most likely move forward. The best defense in this case is often a fast and effective early action through negotiations to resolve a miscommunication. Preempting formal charges can expose possible weaknesses in the prosecution’s claims, which can encourage a non-litigated settlement