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Health Care Fraud

As the United States tries to control increases in health care costs, providers and medical billing services have come under closer scrutiny, resulting in a surge in criminal charges. Hospitals, clinics, assisted living facilities, doctors and other medical care providers can be accused of health care fraud when it is alleged they billed an insurance company for unnecessary procedures or services never performed, or when they overbill for services performed. Individuals also can be charged with health care fraud in State or Federal Court.

Being arrested for health care fraud can be overwhelming. If you or someone you know is facing health care fraud accusations, contact Goldstein & Orr today. Our criminal defense attorneys can work hard to build a solid defense on your behalf and seek the best results for you.

San Antonio Health Care Fraud Lawyer, TX

If you or your company is facing a criminal investigation for health insurance fraud, Medicare fraud or Medicaid fraud, contact a fraud defense attorney at Goldstein & Orr to discuss your case. Our lawyers are experienced in fighting health care fraud cases in both state and federal court. We represent clients in San Antonio and throughout Texas.

Fraud charges are serious and can result in jail time and steep fines. It is important you choose a criminal defense lawyer who can help you build a strong defense. At Goldstein & Orr, our attorneys have the sophisticated knowledge and extensive experience to fully protect your rights at every stage of your criminal case. Call (210) 226-1463 today for a free consultation.

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Overview of Health Care Fraud

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Types of Health Care Fraud

Our team is experienced in defending those accused of health care fraud, including doctors, patients, claims adjusters and others. You can turn to us in cases involving accusations of any of the following forms of white collar crime:

  • Doctors illegally offering payments for patient referrals
  • Patients filing false medical insurance claims
  • Doctors taking liens to provide care for patients
  • Doctors committing Medicare fraud by upcoding claims
  • Related conspiracy charges

Defending these cases requires a detailed, aggressive and sophisticated defense. For that reason, we frequently bring in the top investigators and experts to prepare the case for pre-trial motion hearings and trial. We will use all resources possible to help defend your rights.

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Insurance and Health Care Fraud is Rampant

State and federal investigators have focused tremendous resources in recent years on efforts to control insurance fraud, health care fraud and excess medical claims. Insurance companies also have increased efforts to find and prevent fraudulent claims. When such claims are found, the investigations often are turned over to state and federal investigators.

“This danger is doubly troubling in light of recent fears that insurance fraud is rampant. Although its exact magnitude is difficult to ascertain for obvious reasons, various estimates suggest that excess medical claims alone may add over $100 per year to the average cost of auto insurance for each customer, that about 10 percent of all auto insurance claims are fraudulent, that property/casualty insurance fraud may amount to about $20 billion annually, that health care fraud may be as much as $100 billion annually, and that workers’ compensation fraud may account for as much as 25 percent of all claims. It has even been suggested that insurance fraud is second only to illegal drug trafficking in the amount of illicit revenue that it generates for perpetrators.”

Alan O. Sykes, “Bad Faith” Breach of Contract by First–Party Insurers, 25 J. Legal Stud. 405, 434–435 (1996) (footnotes omitted).

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Federal Health Care Law Violations

Health care fraud also is a federal crime, pursuant to 18 U.S.C. § 1347. It prohibits knowingly and willfully executing a scheme to defraud any health care benefit program. The statute calls for a statutory maximum penalty of 10 years in prison. If any serious bodily injury resulted from the fraud, then the statutory maximum penalty is 20 years incarceration. If any violation resulted in the death of another person, the penalty would include imprisonment for life.

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Texas Medicaid Fraud Claims

The Texas Medicaid Program is maintained by the Texas Health and Human Services Commission (THHSC). Medicaid providers such as hospitals enter into Medicaid provider agreements with the THHSC. Thereafter, the providers perform medically necessary treatment to Texas Medicaid beneficiaries and submit claims to the THHSC for reimbursement.

The responsibility for reviewing and determining the payment or denial of claims submitted by enrolled healthcare providers fails upon the THHSC’s Office of Inspector General (OIG). The Texas legislature has given the OIG the task of “prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state … and the enforcement of state law relating to the provision of those services.” See Tex. Gov’t Code Ann. § 531.102(a) (West Supp.2013).

When the THHSC’s Office of Inspector General finds fraud and abuse in Medicaid, it is authorized to impose sanctions against the offending provider.

The statutory scheme gives the OIG the power to determine the “appropriate administrative enforcement, including recoupment and other necessary administrative action, sanction or penalty” when it finds “[p]rima facie cases of misuse, waste, abuse or fraud.” Id. § 371.1701 (2011) (Tex. Health & Human Servs. Comm’n, Inspector General Investigation of Overpayments) repealed 37 Tex. Reg. 7998 (2012) (proposed Aug. 10, 2012).

The OIG is also “responsible for the enforcement of state law relating to the provision of health and human services in Medicaid.” 1 Tex. Admin. Code § 371.1(c) (2010). Those criminal investigations are conducted against patients, doctors, hospitals, clinics and others involved in the Texas Medicaid program. See Tex. Admin. Code § 371.11(a) (2013).

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Additional Resources

FBI: White Collar Crimes –  Access the official webpage for the FBI to learn more about white collar crimes. You can read about money laundering, investment fraud, identity theft, commodities fraud, and more.

Texas Penal Code: Health care fraud –  Click on the link provided to view section 35A of the Texas Penal Code which discusses Health Care Fraud. Access the page to read the elements that constitute the offense and how TX penalizes the crime.

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Health Care Fraud, Bexar County, TX

Our experienced criminal defense attorneys represent patients and medical care providers under investigations for insurance fraud, health care fraud, Medicaid fraud and Medicare fraud throughout the state courts in Texas and the federal courts. In addition to health care fraud, our attorneys are experienced in defending related charges of conspiracy to commit health care fraud and conspiracy to offer and receive kickbacks and bribes in connection with goods or services for which Medicare made payments, other violations of federal anti-kickback laws and violation of excess compensation laws.

If you have been arrested for any type of health care fraud in Bexar County, contact Goldstein & Orr today. Our attorneys serve clients in Bexar County and surrounding cities including San Antonio, Leon Valley, Converse, Live Oak, Schertz, Canyon Lake, and Pleasanton, TX. Call Goldstein & Orr today at (210) 226-1463 to discuss the facts of your case.

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