Health care fraud generally involves attempting to defraud a health insurance company, government healthcare program, service provider, or patient. Health care fraud can involve state and federal criminal charges and lead to serious jail time, fines, and reimbursement for any fraudulent gains.

The healthcare industry, government, and insurance programs can be complicated and confusing. A simple mistake or misunderstanding can lead to accusations of health care fraud. If you were accused of health care or Medicare fraud in Charlottesville, talk to an experienced criminal defense lawyer to understand your rights and defenses.

Health Care Fraud Laws in Virginia

Health care fraud can involve both state and federal criminal charges. If health care fraud only involves Commonwealth programs or providers, the case may be handled as a state crime.

Under Virginia Code § 63.2-522, it is theft to obtain public assistance or benefits by means of a willful false statement or representation, by impersonation, or other fraudulent device. This may include filing a false application to get state medical benefits or using another person's personal information to get medical treatment.  

Federal Health Care Fraud Laws

When health care fraud involves a health care benefit program, like Medicare or other federal benefit programs, health care fraud can be a federal offense.

Under 18 U.S. Code § 1347, health care fraud involves knowingly and willfully executing a scheme to:

1. Defraud any health care benefit program; or
2. To obtain, by false or fraudulent pretenses, representations, or promises, and of the money or property owned by, or under the custody or control of, any health care benefit program.

Examples of Health Care Fraud in Fraud

Anyone involved in the medical industry may be accused of health care fraud in Virginia. This includes:  

• Patients,
• Doctors,
• Insurance companies,
• Hospitals,
• Nursing homes,
• Medical equipment companies,
• Medical laboratories,
• Pharmacists,
• Chiropractors,
• Dentists,
• Rehab providers,
• Medical transportation companies, or
• Other health care providers.

According to the Office of the Attorney General in Virginia, some common health care fraud schemes include:

• Billing for services never provided,
• Paying kickbacks for referrals,
• Billing for medically unnecessary tests or procedures,
• Upcoding or inflating the services provided,
• Charging unrelated expenses to Medicaid,
• Double billing, or
• Staging accidents or exaggerating injuries for disability or workers' comp benefits.

As an example: Michael has Medicaid benefits and goes to the doctor's office for a stomach ache. The doctor believes Michael is suffering a temporary stomach ache and tells him to get some over-the-counter gas relief medication.

When billing Medicaid, the doctor includes a different diagnosis and uses treatment codes for x-rays, lab tests, and prescription drugs. The doctor also claims the treatment required double the doctor's actual time spent and the time of 2 nurses, who never saw the patient.

In this example, the doctor may be committing healthcare fraud by billing for goods and services never provided and/or upcoding for procedures to get more money from Medicaid.

Penalties for Health Care Fraud in Virginia

The penalties for healthcare fraud in Virginia will depend on whether it involves state and/or federal charges, the extent of the fraud, and whether anyone was injured as a result of the fraud.

As a federal crime, the penalties for health care fraud can include a fine and up to 10 years in prison. If the violation results in serious bodily injury, the penalties can include a fine and up to 20 years in prison.

There are also serious civil penalties associated with health care fraud. This includes fines, reimbursement for fraudulent services and charges, damages, and court costs and attorneys' fees.

Under Virginia Code § 8.01-216.3, health care fraud that involves Commonwealth agencies can be treated as fraud against the taxpayer. The Virginia Fraud Against Taxpayers Act provides for civil penalties, including treble damages, and legal fees.

Health Care Fraud Investigations

Health care fraud investigations can involve multiple private and government agencies, including insurance companies, the Virginia Medicaid Fraud Control Unit, and federal prosecutors. These investigations can be based on fraud red flags, patients closely reviewing treatment records, or whistleblowers within the medical practice.

Unfortunately for many people accused of health care fraud, a mistake or misunderstanding can result in criminal and civil charges. This could include accidentally transposing the wrong records, entering in the wrong treatment code, or lack of training for medical office workers. A mistake should not result in jail time and a criminal record. As soon as you learn about a possible health care fraud investigation, contact an experienced Virginia defense lawyer.

Charlottesville Fraud Defense Lawyer

A criminal conviction for fraud can ruin a medical professional's career and damage future job prospects. If you are accused of medical or healthcare fraud in Charlottesville, talk to an experienced criminal defense attorney about how to fight criminal charges and avoid a criminal record. Contact me today for a free consultation.