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Health care fraud is a White Collar crime that involves an individual or organization knowingly making a misstatement and or misrepresentation when they are filing a health care claim.
Normally, the goal is to make a profit from the claim or to receive a benefit from it.
This does not involve making a mistake on a claim accidentally because it is a crime targeted at those who intend and knowingly choose to deceive for their own gain.
It can be committed by patients, insurers and even providers of health care.
For example, this could include making duplicate claims and filing claims for services, but in fact the services were never used.
Health fraud can be carried out on private and public health insurers.
Who Investigates Health Care Fraud?
There are state and federal laws in place to tackle health fraud.
This means that the states will investigate the crime for state violations, but on a Federal Level it will be the Department of Health and Human Services (HHS OIG) Office of the Inspector General or Federal Bureau of Investigations (FBI).
HHS OIG help the US Attorney – DOJ decide whether an individual or organization should be charged with health care fraud and any other crime. The federal law will always apply in a case.
This means that it will still apply in all states even if there are laws in place there.
This is essential to know since there are more severe penalties associated with a guilty verdict in federal law.
Health fraud is outlined under 18 U.S.C Section 1347. It is important to remember that in order for state and federal investigation of health fraud, there must be intent.
Someone that makes an honest mistake will not be charged and investigated for health fraud. They must ‘knowingly and willfully execute’ health care fraud.
What are the Penalties for Health Care Fraud?
State and Federal punishments will vary depending on the location and severity of the crime. Federal laws outline civil and criminal penalties for health fraud.
Indeed, criminal penalties are more serious and have severe consequences. For civil cases, restitution can be awarded. But you can receive a lengthy prison sentence for being found guilty of criminal health care fraud.
This includes up to 10 years for making a false claim or statement for Medicaid or Medicare.
There can also be significant fines. For individuals this can be up to $250,000 and organizations can be charged up to $500,000. It is possible for a probation sentence to be given. This will include specific conditions to be followed.
Health Fraud Examples
PITTSBURGH, Pa. – A resident of Pittsburgh, Pennsylvania, pleaded guilty in federal court to one count each of conspiracy to defraud the Pennsylvania Medicaid program and health care fraud, United States Attorney Scott W. Brady announced today.
Julie Wilson, 48, pleaded guilty before United States District Judge Cathy Bissoon.
During her plea hearing, Wilson admitted that, at various times between 2011 and 2017, she was an employee of Moriarty Consultants, Inc. (MCI) and Everyday People Staffing, Inc. (EPS), two related entities operating in the home health care industry.
The other entities were Activity Daily Living Services, Inc. (ADL) and Coordination Care, Inc.
ATLANTA –Two metro-Atlanta chiropractors, Allan Spagnardi and Stacy Spagnardi, have been sentenced to federal prison for using their chiropractic clinic to commit healthcare fraud and for defrauding the Internal Revenue Service.
“These chiropractors used their patients’ personal information to obtain over a million dollars from a private insurance company,” said U. S. Attorney Byung J. (“BJay”) Pak.
“Then they went further by engaging in a lengthy scheme to hide their income from the IRS. Healthcare professionals who defraud insurance companies do not just abuse the trust afforded to them by their patients and they also drive up healthcare prices for honest citizens throughout the country.”
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