Health Care Fraud Defense Lawyers in Baltimore
Defending Clients in Maryland, Washington, D.C. & Beyond
Health care providers know that treating patients involves complex regulations and reimbursement procedures, including oversight from private insurers, as well as state and federal agencies. State and federal investigators periodically contact health care providers and review billing practices and procedures. Unfortunately, those investigations can elevate from routine audits to full-blown grand jury investigations and criminal proceedings. They can also lead to federal False Claims Act civil actions involving potentially huge fines and penalties.
What is Health Care Fraud?
Health care fraud generally refers to intentionally deceiving or defrauding a health care program or provider for financial gain. In Maryland, health care fraud is addressed under both state and federal laws, as it involves violations of federal programs such as Medicare and Medicaid.
Here are some common examples of health care fraud:
Billing Fraud: This involves intentionally submitting false claims or manipulating billing codes to obtain reimbursement for services or procedures that were not provided or were medically unnecessary. Examples include assigning a higher-level billing code to a service or procedure to obtain a higher reimbursement rate than what is justified (i.e., upcoding), billing for services or procedures that were never performed (i.e., phantom billing), separating bundled services and billing them individually to increase reimbursement (i.e., unbundling).
Kickbacks and Illegal Referrals: Offering or receiving payments, kickbacks, or incentives in exchange for patient referrals, services, or purchases. Examples include paying or receiving illegal payments in exchange for referring patients to specific providers or for using certain medical products or services (i.e., kickbacks), as well as physicians referring patients to facilities or services that share financial interest, violating anti-kickback and self-referral laws (i.e, self-referral).
Prescription Fraud: Illegally obtaining, distributing, or prescribing prescription drugs. Examples include forging prescriptions or altering existing prescriptions (i.e., prescription forgery), as well as clinics or physicians prescribing and dispensing excessive amounts of controlled substances without legitimate medical needs (i.e., pill mills).
Falsifying Medical Records: Altering or fabricating medical records or documentation to support fraudulent claims or to conceal improper practices.
Identity Theft: Using another person's identity or insurance information to obtain medical services, prescriptions, or reimbursements fraudulently.
Home Health Care Fraud: Billing for unnecessary home health care services or inflating the number of visits or services provided.
Medical Equipment Fraud: Submitting fraudulent claims for durable medical equipment (DME) that was never provided or not medically necessary.
False Diagnosis or Treatment: Misrepresenting or exaggerating a patient's condition or providing unnecessary tests, procedures, or treatments to increase billing.
Telemedicine Fraud: Fraudulent practices related to telemedicine services, such as billing for virtual consultations that did not occur or prescribing medications without a valid patient-doctor relationship.
Health Care Fraud Defense
The lawyers at Nathans & Ripke LLP have lectured and published nationally on health care fraud defense, including editing and contributing to a published compliance manual. We have decades of experience representing individual doctors, medical practice groups, pharmaceutical companies, hospitals, home health agencies, durable equipment manufacturers, and skilled nursing facilities.
We have also represented individuals working at all levels of health care services in response to:
- Government investigations
- Document requests
- Grand Jury investigations
- Trials and negotiated dispositions of civil and criminal charges
Attorney Larry Nathans was recently retained to provide health care federal sentencing and appellate expertise for one of four WellCare executives recently convicted in the United States District Court for the Middle District of Florida (Tampa).
Our Baltimore health care fraud defense lawyers have also represented whistleblowers who have identified fraud and abuse violations in the area and who wish to avail themselves of the qui tam provisions available under federal law.
Is Medicare Fraud a Felony?
Medicare fraud can be a felony. But, it is not always the case; some are just exposed to penalties, fines, exclusion, and so on. Medicare is a federal program, and defrauding the government and its program is illegal and can lead to federal criminal charges, such as a lengthy sentence in federal prison. So by nature, those who commit Medicare fraud are exposed to criminal charges and they in turn can be convicted of a felony. Anyone who commits Medicare fraud is exposed to criminal or civil liability or both. With that in mind, we provided some information that would help you further understand why some are held criminally liable, and some just pay fines.
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Our firm has established a national reputation for outstanding representation. U.S. News rated our firm as one of the premier white collar defense firms in Maryland. All of our partners have been selected to the list of Maryland Super Lawyers®.