Health care fraud cases generally follow the following timeline: the government becomes aware of a potential offense, an investigation occurs, and the government pursues criminal charges if the investigation leads to evidence to support the allegations. It may seem like a relatively straightforward process, but the reality can be circuitous and time consuming. A recent case provides an example.
A recent case out of New York provides multiple examples of what not to do if accused of health care fraud. The case began when the U.S. Attorney's Office of the Western District of New York investigated a psychiatric physician for health care fraud. According to the prosecution, the physician billed for the highest level of evaluation appointments when seeing new patients. When questioned about the need for such an inclusive appointment, the government claims he was unable to provide sufficient evidence to support the claim. Upon further investigation, the government claims the physician routinely up coded and improperly billed for services.
Lawmakers designed the federal Anti-Kickback Statute (AKS) to help better ensure medical professionals focus on the well-being of their patients. Lawmakers intended this piece of regulation to reduce the risk of medical decisions based on financial gain. But what happens when the government accuses a medical company or individual of an AKS violation? The following discussion provides a basic timeline.
Those who face allegations of health care fraud can find themselves fighting an uphill battle. The government can gather evidence and witnesses to testify against you, but defensive strategies are available to help you defend your professional reputation. One strategy to use during a health care fraud trial: cross examination.
A United States district judge recently sentenced a health care executive after the government accused him of running an elaborate network that benefited from the use of illegal referrals. According to the indictment, the accused owned and operated skilled nursing facilities and assisted living facilities. The government accused the businessman of using illegal bribes and kickbacks to encourage medical professionals to recommend the use of his businesses to patients.
The United States Department of Health and Human Services (HHS) continues to crackdown on allegations of healthcare fraud. The government will strike both before and after the fraudulent activity occurs. Predictive analytics allow federal investigators to flag potential violations before they occur. This tool, paired with federal investigations, allows government agencies multiple tools to gather evidence to build support allegations of fraudulent activity.
The government continues to pursue Insys related healthcare fraud investigations. Insys Therapeutics (Insys), a pharmaceutical giant, is known for manufacturing Subsys, a fentanyl-based spray used for management of severe pain suffered by cancer patients.
The United States Attorney for the Western District of New York has charged a local psychiatrist with health care fraud. The medical professional operates a private practice, has served with many nursing homes and has also spoken at consulting engagements for pharmaceutical companies.
In recent years, the government has been taking a much more aggressive approach to health care fraud enforcement, and it looks like enforcement efforts could get even more aggressive under the Trump administration.