Healthcare Fraud Defense Lawyer

In the intricate world of healthcare, where the lines between regulatory compliance and legal transgressions can often blur, Varghese & Associates, PC stands as a bulwark against unjust accusations of fraud. Our seasoned team of criminal defense lawyers, based in the heart of New York City, is dedicated to defending healthcare professionals, organizations, and entities against allegations of healthcare fraud. With a profound understanding of both state and federal healthcare laws, we provide our clients with robust defense strategies designed to protect their professional licenses, reputations, and livelihoods.

What Constitutes Healthcare Fraud in NYC?

Healthcare fraud in New York City, as in the rest of the United States, involves the deliberate submission of false claims or the dissemination of false information to receive payment from government-funded healthcare programs (like Medicare or Medicaid) or private insurance companies. The state of New York has specific laws and regulations that govern healthcare practices, in addition to federal laws. Here’s an overview of activities that are commonly recognized as constituting healthcare fraud:

1. Billing for Services Not Rendered

This includes submitting claims for medical services, procedures, or supplies that were never actually provided to the patient.

2. Upcoding Services and Procedures

Upcoding occurs when a healthcare provider submits a bill using a code that yields a higher payment than the code for the service or procedure that was actually performed.

3. Performing Unnecessary Procedures

Some providers might perform unnecessary medical procedures on patients to increase the amount billed to insurance companies or government healthcare programs.

4. Misrepresenting Non-Covered Treatments

Healthcare providers may falsely label cosmetic or other non-covered procedures as medically necessary treatments in order for them to be paid by the insurance provider.

5. Kickbacks and Referral Fees

Receiving or paying compensation in exchange for the referral of patients for services or products that will be paid for by healthcare programs is illegal and considered a form of healthcare fraud.

6. Falsifying Patient Records

This involves altering patient records to justify unnecessary tests or procedures or to support fraudulent claims.

7. Prescription Fraud

Includes prescribing unnecessary medications, prescriptions for non-existent patients, or billing for never filled prescriptions.

Legal Frameworks and Enforcement

Healthcare fraud is taken very seriously by both state and federal authorities. It’s typically investigated by various agencies, including the New York State Office of the Medicaid Inspector General (OMIG), the Federal Bureau of Investigation (FBI), and the Department of Health and Human Services’ Office of Inspector General (HHS-OIG).

At the federal level, healthcare fraud is primarily prosecuted under the False Claims Act, the Anti-Kickback Statute, and the Stark Law. New York State also has its own set of laws and regulations designed to combat healthcare fraud, including the New York False Claims Act, which mirrors the federal False Claims Act but applies to state healthcare programs.

Penalties for Healthcare Fraud

Penalties for healthcare fraud can be severe and varied, impacting individuals and entities on multiple levels and involving criminal, civil, and administrative actions. These penalties punish wrongdoers, deter future fraud, and recover unlawfully obtained funds. The specific consequences depend on the nature of the fraud, the amount of money involved, and the jurisdiction. Here’s a broad overview of potential penalties for healthcare fraud:

Criminal Penalties

• Prison Time: Individuals convicted of healthcare fraud can face significant prison sentences. The length of imprisonment can vary widely depending on the case’s specifics, including the amount of money involved and whether the fraud harmed patients. Under federal law, for instance, fraud involving a government healthcare program can result in up to 10 years in prison per offense, and if the fraud results in serious bodily injury, the sentence can increase up to 20 years. If the fraud results in death, life imprisonment is possible.
• Fines: If convicted of healthcare fraud, both individuals and entities can face substantial fines. Under federal law, fines can reach up to $250,000 for individuals and $500,000 or more for entities per offense. State laws may impose additional fines.

Civil Penalties

• Financial Damages and Restitution: Defendants found liable for healthcare fraud may be ordered to pay restitution to the victims, including government agencies or private insurers, to compensate for the losses incurred due to the fraudulent activities. Additionally, under laws such as the False Claims Act, defendants may be liable for treble damages, meaning they must pay three times the amount of the fraudulently billed claims.
• Civil Monetary Penalties (CMPs): The Office of Inspector General (OIG) can impose CMPs for various forms of healthcare fraud. These penalties can be substantial, ranging from $11,000 to $50,000 per false claim, plus an assessment of up to three times the amount of damages sustained by the government.

Administrative Penalties

• Exclusion from Federal Healthcare Programs: Individuals and entities convicted of healthcare fraud may be excluded from participating in federal healthcare programs such as Medicare and Medicaid. This exclusion can effectively end a healthcare provider’s career or a business’s operations by cutting off their primary source of revenue.
• Loss of Professional Licenses: Healthcare professionals found guilty of fraud can face disciplinary actions, including suspension or revocation of their professional licenses, administered by state licensing boards.

Additional Consequences

• Reputational Damage: The reputational harm from healthcare fraud allegations or convictions can be devastating and long-lasting for professionals and organizations, affecting their ability to practice or do business in the future.
• Increased Scrutiny: Entities that settle fraud allegations or that are convicted of healthcare fraud may also be subject to increased scrutiny and oversight, such as Corporate Integrity Agreements (CIAs), which mandate compliance with certain practices and reporting requirements.

The complexity and severity of healthcare fraud penalties underscore the importance of legal representation and compliance efforts to prevent accidental or intentional fraudulent activities within healthcare practices.

How a Healthcare Fraud Defense Lawyer Can Help

As a premier criminal defense law firm, Varghese & Associates, PC, has experience in defending clients against allegations of healthcare fraud. Our skilled healthcare fraud defense lawyers are well-versed in the complexities of both state and federal healthcare laws. If you or your organization is facing healthcare fraud charges, here is how we can assist:

Comprehensive Case Evaluation

We begin by thoroughly evaluating your case, scrutinizing the allegations, examining the evidence, and identifying any procedural errors or substantive defenses that could be pivotal to your case. This initial step allows us to craft a strategic approach tailored to your situation.

Expert Negotiation

Our legal team possesses extensive experience in negotiating with prosecutors and regulatory agencies. We aim to achieve the best possible outcome for our clients, whether that involves reducing the charges, minimizing potential penalties, or, when possible, having the charges dropped entirely.

Aggressive Litigation

If your case goes to trial, you can count on our seasoned litigators to defend you vigorously. We prepare meticulously, ensuring that we present the strongest possible defense. Our team is adept at challenging the prosecution’s evidence, cross-examining witnesses, and presenting compelling arguments to protect your rights and interests.

Personalized Legal Representation

At Varghese & Associates, PC, we understand that facing healthcare fraud charges can be a daunting experience. That’s why we are committed to offering personalized legal representation. We take the time to understand your specific circumstances, concerns, and objectives. Our client-centered approach ensures that you are informed and supported throughout the legal process.

Signs You’re Being Investigated for Healthcare Fraud

Recognizing the early signs of a healthcare fraud investigation is crucial for healthcare professionals and organizations. Early detection allows for prompt action and preparation of a defense strategy. Here are key indicators that you might be under investigation for healthcare fraud:

1. Unusual Requests for Information

If you receive unexpected requests for medical records, billing records, or other documentation from government agencies like Medicare or Medicaid, insurance companies, or entities acting on their behalf, it could be a sign of an ongoing investigation. These requests often precede formal charges or announcements of an investigation.

2. Patients or Employees Receiving Subpoenas or Inquiries

When investigators contact patients, current or former employees, or colleagues or receive subpoenas for information related to your practice, it might indicate that you are being investigated. These individuals could be asked to provide testimony or documents concerning your billing practices or patient care.

3. Banking and Financial Irregularities

Notices from your bank about frozen accounts or inquiries into your financial transactions can be red flags. Investigators often review financial records to trace the flow of funds when they suspect healthcare fraud.

4. Audits by Insurance Companies or Government Entities

While routine audits are a standard part of healthcare operations, an increase in the frequency of audits or audits that are more invasive than usual can be a sign of an underlying fraud investigation. This is especially true if the auditors are focusing on specific areas of billing or particular types of claims.

5. Interviews with Law Enforcement or Regulatory Agencies

If you or your staff are approached by law enforcement officers or representatives from regulatory agencies like the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), or the FBI for interviews, it’s a significant indication of an investigation.

6. Communication from a Whistleblower

Whistleblowers play a significant role in healthcare fraud investigations. If you become aware of communications or actions taken by individuals who may have whistleblower information, it’s wise to consider the possibility of an investigation. Whistleblowers can initiate investigations by reporting fraudulent activities to authorities or through qui tam lawsuits under the False Claims Act.

7. Notification of an Investigation

The most unequivocal sign of an investigation is receiving a formal notification or letter indicating that you or your practice is under investigation for healthcare fraud. This notification may come from a government agency, law enforcement, or an attorney representing a whistleblower.

What To Do If You’re Facing Criminal Charges for Healthcare Fraud

Taking immediate and strategic actions is crucial if you’ve been charged with healthcare fraud. Here’s a concise list of steps to follow if facing criminal charges:

• Contact a Criminal Defense Attorney With Experience in Healthcare Fraud: Secure representation from a lawyer with experience in healthcare law and criminal defense.
• Do Not Discuss Your Case with Anyone but Your Fraud Defense Lawyer: Conversations about your case should be confidential and limited to your legal counsel to protect your rights.
• Preserve All Relevant Documents: Gather and save all medical records, billing information, emails, and correspondence related to the charges. Do not destroy any potential evidence.
• Comply with Legal Requirements: Follow any court orders, such as appearances or document submissions, but always consult your attorney before taking action.
• Review Your Insurance Policies: Determine if your professional liability insurance covers legal defense costs in healthcare fraud cases.
• Prepare for Financial Implications: Be aware of the potential for asset freezes or fines and plan accordingly with the advice of your attorney.
• Stay Informed About the Legal Process: Understand the charges against you, the potential penalties, and the legal process ahead with the help of your attorney.
• Consider the Impact on Professional Licensing: Discuss with your attorney the potential effects on your medical or professional license and any actions you might need to take with licensing boards.
• Do Not Contact Alleged Victims or Witnesses: Do not contact anyone involved in the investigation or prosecution of your case to avoid potential accusations of tampering.
• Focus on Your Well-being: Legal battles can be stressful. Consider seeking support for your mental and emotional health during this challenging time.

Acting promptly and judiciously can significantly affect the outcome of your case.

Ready to Protect Your Future? Contact Us Today.

Facing healthcare fraud allegations can be overwhelming, but you don’t have to navigate this challenging time alone. At Varghese & Associates, PC, our dedicated team of healthcare fraud defense lawyers is equipped with the experience to defend your rights and secure the best possible outcome for your case. Don’t let charges dictate your future—take the first step towards reclaiming your professional integrity and personal peace of mind.

Get in touch with us now for a confidential consultation. Together, we can work towards a solution that protects your career, reputation, and freedom.

Healthcare Fraud Defense Lawyer FAQs

What is healthcare fraud?

Healthcare fraud involves knowingly and willfully executing, or attempting to execute, a scheme to defraud any healthcare benefit program or to obtain money or property by means of false or fraudulent pretenses, representations, or promises related to healthcare payment or delivery.

Why do I need a lawyer with experience in healthcare fraud?

An experienced healthcare fraud defense lawyer is familiar with the complexities of healthcare laws and regulations and the legal processes involved in fraud cases. They can navigate the nuances of both criminal and civil aspects of healthcare fraud, providing you with a defense that understands the specific legal landscape.

Can healthcare fraud charges be dropped or reduced?

Yes, with an effective defense strategy, it’s possible to have charges reduced or even dropped. Factors such as lack of intent to defraud, insufficient evidence, and procedural errors can be pivotal in the outcome of a case.

What are the penalties for healthcare fraud?

Penalties can include imprisonment, fines, restitution payments, loss of professional licenses, exclusion from federal healthcare programs, and reputational damage. The severity of the penalties depends on the specifics of the fraud, the amount of money involved, and whether patients were harmed.

How can a healthcare fraud defense attorney help me?

• Case Evaluation: Analyze the charges and evidence to develop a defense strategy.
• Legal Guidance: Navigate the complexities of healthcare and criminal law.
• Negotiation: Work towards a plea deal or settlement where appropriate.
• Trial Representation: Defend you in court, if the case goes to trial.

What should I do if I’m being investigated for healthcare fraud?

Immediately contact a healthcare fraud defense lawyer without responding to the investigators. Preserve any relevant documentation and refrain from discussing the matter with anyone outside of your legal team.

How long do federal healthcare fraud cases typically last?

The duration can vary widely based on the complexity of the case, the amount of evidence, and whether the case goes to trial. Cases can last from several months to several years.

Can a fraud attorney help me if I’ve already been charged or convicted?

Yes, a federal health care fraud lawyer can help even after charges have been filed or a conviction has been made. They can assist with appeals, negotiate for reduced sentencing, and provide guidance on compliance and mitigating future risks.

What is the difference between healthcare fraud and medical malpractice?

Healthcare fraud involves intentional deception for financial gain, while medical malpractice refers to negligence or failure to provide an acceptable standard of care, which is not necessarily related to fraud.

How much does hiring a healthcare fraud defense lawyer cost?

Costs can vary depending on the complexity of the case and the health care fraud defense lawyer’s experience. Many white-collar criminal defense lawyers charge an hourly rate, while others may offer flat fees for certain services. Discuss payment structures and expectations upfront with your attorney.

Consulting with a skilled healthcare fraud defense lawyer at the earliest sign of trouble can significantly impact the resolution of your case, protecting your professional career and personal life from the severe consequences of fraud allegations.