Overbilling in Healthcare Fraud: Defending Against Federal Charges

Overbilling in Healthcare Fraud Criminal Cases: What You Need to Know

Overbilling in healthcare is a critical issue that has landed countless providers, administrators, and healthcare professionals across the United States in legal trouble.

In many cases, an administrative error can also result in allegations of criminal fraud. Federal agencies like the Office of Inspector General (OIG), Department of Justice (DOJ), and Federal Bureau of Investigation (FBI) aggressively investigate these cases, often leading to severe penalties under laws like the False Claims Act (FCA).

Understanding the stakes, the legal definitions, and how a federal healthcare fraud lawyer can help is essential if you are under investigation for overbilling or related healthcare fraud charges like Anti-Kickback Statute violations.

What is Overbilling in Healthcare?

The federal health care fraud statute is 18 USC 1347. It makes it a crime to knowingly defraud a health care benefit program. Overbilling in healthcare occurs when healthcare providers or organizations bill insurance programs, including Medicare or Medicaid, for services or items that were not rendered, were unnecessary or were improperly coded to receive higher reimbursements. Common forms include:

• Upcoding: Billing for a more expensive service than the one provided.
• Unbundling: Separating procedures meant to be billed as a single package to increase reimbursement.
• Billing for Nonexistent Services: Charging for procedures or services never rendered.
• Duplicate Billing: Submitting multiple claims for the same service.

Healthcare overbilling is not merely an administrative misstep in criminal cases—it is often prosecuted as healthcare fraud.

The Seriousness of Healthcare Fraud Charges

Healthcare fraud, including overbilling, is treated as a federal crime. Convictions can result in significant prison time, steep financial penalties, and professional consequences, such as losing medical licenses. A notable example is the case of a man sentenced to 16 years in prison for orchestrating a $336 million healthcare fraud scheme. This involved overfilling and wire fraud, and the individual also faced identity theft charges.

This case highlights how federal agencies work together to identify fraudulent activities in the healthcare sector. Penalties often include restitution, forfeiture of assets, and long-term consequences for your professional reputation.

Anti-Kickback Statute and Overbilling

The Anti-Kickback Statute (AKS) is another law that frequently intersects with overbilling in healthcare fraud cases. This statute prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of services covered by federal healthcare programs.

If overbilling is combined with AKS violations—for example, paying kickbacks for patient referrals—penalties can escalate dramatically. Convictions under the AKS can result in up to five years in prison, in addition to other fines and penalties.

If you’re charged with violating the AKS alongside criminal. allegations, you need a healthcare fraud defense lawyer to build a robust legal strategy.

Federal False Claims Act and Overbilling

The Federal False Claims Act (FCA) is one of the most powerful tools the DOJ uses to combat overbilling. Under the FCA, individuals or entities who knowingly submit false claims for payment to the federal government can be held liable for treble damages and penalties.

Whistleblowers, often employees within healthcare organizations, play a key role in FCA cases. They can file qui tam lawsuits, which allow private individuals to bring claims on behalf of the government. If successful, whistleblowers may receive a percentage of the recovered funds.

The FCA’s civil penalties can reach tens of thousands of dollars per false claim, and criminal prosecution may follow if intentional fraud is proven.

The Role of a Federal Healthcare Fraud Lawyer for 18 USC 1347 Criminal Charges

When facing accusations of overbilling, securing a skilled healthcare fraud defense lawyer is critical. These cases often involve:

1. Complex Federal Investigations: Agencies like the FBI, OIG, and DOJ have extensive resources to investigate and prosecute fraud.
2. Serious Charges: Accusations can lead to federal indictments, which carry severe penalties, including prison sentences.
3. Reputation at Stake: Beyond legal penalties, healthcare fraud charges can tarnish professional reputations and careers.

A seasoned healthcare fraud lawyer can help by:

• Challenging Evidence: Questioning the validity of billing audits, whistleblower claims, and government investigations.
• Negotiating Settlements: In some cases, resolving charges through settlements can minimize penalties and avoid trial.
• Building a Defense: Asserting that overbilling  under 18 USC 1347 was unintentional or due to systemic errors, not fraud.

Steps to Take if Accused of Overbilling

1. Contact a Healthcare Fraud Defense Lawyer Immediately
   Early legal intervention can make a significant difference. Your attorney can guide you on how to respond to subpoenas, audits, or investigations.
2. Preserve All Documentation
   Gather all relevant billing records, emails, and other documentation to prepare for the investigation.
3. Avoid Discussions Without Legal Counsel
   Anything you say to investigators or auditors could be used against you. Always have legal representation during interviews.
4. Review Billing Practices
   Conduct an internal audit to identify potential issues and rectify them before they escalate.

The Consequences of a Criminal Conviction

Criminal convictions for overbilling and healthcare fraud can result in:

• Prison Time: Federal sentencing guidelines impose severe penalties, with sentences often ranging from 5 to 20 years.
• Financial Penalties: Fines, restitution, and forfeiture can result in millions of dollars in losses.
• Career Ruin: Professionals may face licensure revocation and exclusion from federal healthcare programs.

Criminal Penalties for Federal Healthcare Fraud

Healthcare fraud is a serious federal offense with strict penalties that reflect the severity of its impact on government programs, taxpayers, and patients. Federal prosecutors take an aggressive stance in pursuing individuals and entities accused of healthcare fraud, particularly in cases involving Medicare and Medicaid. Understanding the penalties and legal elements involved is crucial for anyone facing these allegations.

Severe Prison Sentences

Under federal law, individuals convicted of healthcare fraud can face significant prison time. The base penalty is up to 10 years in prison per offense. However, certain aggravating factors can increase the sentence. For example:

• If the fraud results in serious bodily injury, such as harm caused by unnecessary medical procedures billed fraudulently, the prison sentence can extend to 20 years.
• In cases where fraud contributes to a patient’s death, defendants may face life imprisonment.

These penalties of 18 USC 1347 underscore the gravity of federal healthcare fraud convictions and their lasting impact on the accused.

Financial Consequences

In addition to prison sentences, financial penalties are a significant component of healthcare fraud convictions. These may include:

1. Fines: Convicted individuals and organizations can face fines of up to $250,000 per offense or higher in cases involving large-scale fraud.
2. Restitution: Courts often require defendants to pay restitution, compensating federal healthcare programs, patients, or insurance companies for losses incurred.
3. Forfeiture of Assets: Assets acquired through fraudulent means, such as properties or vehicles purchased with illicit funds, may be seized by the government.

The financial burden of these penalties can devastate individuals and organizations, often leading to bankruptcy or the permanent closure of healthcare practices.

What are the Key Elements of Healthcare Fraud

To secure a conviction for healthcare overbilling fraud, prosecutors must prove certain elements beyond a reasonable doubt:

1. Intent to Defraud: The defendant must have knowingly and willfully engaged in fraudulent conduct. Simple errors or negligence typically do not meet this standard.
2. False or Misleading Claims: Fraud often involves submitting claims to federal programs, such as Medicare or Medicaid, that contain false, incomplete, or misleading information.
3. Financial Gain: The fraudulent actions must be aimed at obtaining money, services, or property unlawfully.

These elements are critical in building the government’s case and demonstrate why legal representation is vital. A skilled federal healthcare fraud defense lawyer can challenge the government’s evidence and establish that intent or knowledge of wrongdoing was absent.

Protect Your Future

If you are facing allegations of medical overbilling fraud, do not underestimate the seriousness of these charges. The combination of federal statutes like the False Claims Act and Anti-Kickback Statute creates a high-stakes environment where experienced legal representation is essential.

By working with a knowledgeable healthcare fraud lawyer, you can navigate these complexities, challenge accusations, and protect your professional and personal future.

For more information about federal medical fraud defense under 18 USC 1347, contact a dedicated healthcare fraud defense lawyer today. Call Theodore Watson at 1.866.601.5518.