Health care providers are subject to some of the strictest regulations mandated by federal laws. Currently, the Department of Justice uses two primary statutes when looking to seek civil penalties from health care providers. While these civil penalties do not include jail time, they still carry long-term consequences that impact a physician’s reputation, licensing, and financial well-being.
Civil Laws Affecting Physicians and Health Care Fraud
- The False Claims Act (FCA) – The FCA combats Medicare fraud and prohibits a medical provider from presenting false claims for payment from federal government insurance programs including Medicare and Medicaid. This statute covers various false claims including upcoding, submitting requests for procedures not provided to the patient, and other types of malicious claims. If found guilty, you could face triple the damages plus any civil penalties the court feels justified. Under the FCA, a whistleblower (which could be a patient or employee), can file a government lawsuit against you.
- Stark Law – Stark Law prohibits physicians from referring their patients to other health care services that benefit the physician. For example, a physician that also owns a chiropractic firm could not refer patients to that chiropractic firm. The relationship does not have to be as blatant as owning the stock. If a financial relationship or interest exists, the physician cannot refer. All payments made will be refunded, and the statute allows for up to $15,000 per service as a penalty.
Criminal Laws Affecting Physicians and Health Care Fraud
Health care fraud is not limited to civil penalties. While most health care fraud cases fall under the civil laws, these criminal violations do happen. That means the guilty party could face penalties, jail time, and the loss of their license.
- Anti-Kickback Statute (AKS) – AKS is a criminal, not civil, statute. It prohibits any company or individual from offering something of value to a physician for a referral. This includes giving gifts to physicians to encourage them to prescribe medications to their patients. Any violation of this criminal statute could result in up to 5 years imprisonment and up to $25,000 in fines.
- Criminal Health Care Fraud Statute – Anyone intentionally attempting to defraud the health care system, using false statements to obtain funds from federal programs, and engaging in fraudulent activities with Medicare billing could face up to ten years imprisonment and fines of $500,000 – or up to two times the fraud amount.
The Importance of Legal Counsel
If you have been accused of health care fraud, it is imperative that you speak with an attorney. Health care fraud can lead to criminal penalties, which means a prison sentence. If you do serve time in prison, you could lose your medical license and face other long-term consequences.
Therefore, it is essential that you hire an attorney that has experience in federal health care fraud defense. The sooner you contact an attorney, the better for your case. An attorney will conduct their own investigation and mount a defense to ensure your future is not jeopardized.