Healthcare fraud is a very serious offense at both the federal and state levels. False claims and unethical practices lead to extensive losses every year. These types of claims can be very costly and have serious consequences.
If you find yourself facing a healthcare fraud case, an Arizona healthcare fraud defense lawyer will guide you through the process and develop the best strategies to move forward. Suzuki Law Offices offer best-in-class defense law and services designed to protect you. By hiring representation, you do not have to handle this situation on your own.
Healthcare Fraud Defined
The federal government is dedicated to preventing healthcare fraud and has several agencies tasked with investigating and prosecuting such claims. Healthcare fraud is committed when a medical provider or individual provides false claims, information, services, or resources for financial gain. This issue affects medical practitioners and patients alike and can be tried in both a civil and criminal capacity, according to the U.S. Department of Justice (DOJ).
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Get StartedMost Common Types of Healthcare Fraud
False claims, forged prescriptions, and incorrect billing are all fraudulent activities that result in profit losses every year. According to the Federal Bureau of Investigation (FBI), there are three main types of healthcare fraud: fraud by medical providers, fraud by patients, and prescription fraud. A closer look at each type of fraud reveals the type of action most prevalent within each category.
Fraud by a Medical Provider
Fraudulent billing is the most common type of activity in this category. These improper billing methods transfer additional costs to the patient and force them to pay for services they never received. Some types of false billing include:
- Submitting more than one claim for a single service (double billing)
- Submitting more than one bill for a single service (unbundling)
- Billing for a service a patient did not receive (phantom billing)
- Billing a service at a higher price (upcoding)
Fraud by a Patient/Individual
Fraud by a patient or individual is most likely to occur through altered or stolen identities. This group pretends that they are someone else in order to game the healthcare system. Fraudulent behavior in this category is demonstrated by:
- Allowing or using another person’s health insurance for care (Identity theft/swapping)
- Providing services without possessing a license (impersonating a healthcare provider)
- Convincing people to provide their insurance ID number, then stealing their identity and opening a false insurance plan (bogus marketing)
Prescription Fraud
Illegal usage and access to medications are considered prescription fraud. Arizona Law addresses prescription fraud in healthcare by focusing on people who either benefit financially or from the effects of the drugs themselves. A person may engage in alternative methods or uses of prescriptions in the following ways:
- Using or creating a prescription that is counterfeit (forgery)
- Selling legal prescriptions (diversion)
- Accessing controlled prescriptions by going to different or unethical doctors (doctor shopping)
Healthcare Fraud Laws
Healthcare fraud is pervasive and costly to medical providers and patients alike. To combat these illegal activities, there are a number of healthcare fraud laws, both on the federal and state levels, designed to prevent, investigate, and prosecute these crimes. Below are some of the most common fraud and abuse laws.
False Claims Act
The False Claims Act protects government entities from being sold poor services and being overcharged. Presenting falsified claims is illegal and can result in steep fines and time in prison. Additionally, if anyone knows or suspects that a false claim is made, they are required to report it in accordance with whistleblower policies.
Anti-Kickback Statute
Healthcare providers are barred from paying for business referrals, according to the Anti-Kickback Statute. If any payments are made for referrals, both monetarily or through alternate rewards, that party has committed a criminal offense and can face a series of penalties and time in jail. This statute extends to referrals by other physicians, patients, contractors, medical device companies, and more.
Physician Self-Referral Law
The Physician Self-Referral Law prevents doctors and other licensed physicians from referring patients anywhere they or their family members are financially involved unless there’s an applicable exception. Any infringement upon these laws can result in fines and exclusion from federal health programs.
Exclusion Statute
The Office of Inspector General excludes anyone who has committed fraud, abused or neglected patients or has felony convictions from participating in any federal health programs. Physicians who are excluded from federal health programs are not allowed to bill or receive payment from these organizations.
Fraud Laws in Arizona
In addition to federal fraud laws, Arizona has laws against healthcare fraud on the state level. According to Statute §13-2310, anyone who has knowledge of a fraudulent benefit and accepts it anyway is guilty of a class 2 felony. Furthermore, someone who has been convicted of fraud may not receive sentence suspension, probation, or pardon until their sentence has been served.
Additionally, Arizona Statute §36-2918 stipulates that the state can investigate fraudulent behavior and implement a subpoena if there is suspicion or discovery that illegal acts were committed. Healthcare fraud can be punished by sharp fines and in accordance with all applicable state and federal laws. However, a person retains their right to appeal the decision.
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Reporting Healthcare Fraud in Arizona
Reporting healthcare fraud is vital for prevention and recovering losses. Arizona statute §32-3208 requires health care professionals to report any misdemeanors or felonies to the regulatory board within 10 days of conviction. Additionally, to report any known or suspected fraudulent behavior, a provider or individual can visit the Arizona Health Care Cost Containment System and complete the online form to initiate an investigation by the Office of Inspector General.
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Hire a Phoenix Criminal Defense Lawyer
If you find yourself facing fraud charges by the federal government, an Arizona healthcare fraud defense lawyer can help protect you. Our legal team at Suzuki Law Offices is nationally recognized and experienced to help you with this complex legal situation. Our clients are our top priority, and we are dedicated to fighting for you every step of the way.
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