Dallas Healthcare Fraud Defense Lawyer

healthcare fraud

Healthcare fraud is a serious problem in Dallas, across Texas, and throughout the country. Medical providers, patients, and others who purposefully deceive the healthcare system for their personal gain can cause billions of dollars in losses each year and, in turn, push medical costs higher. For this reason, the federal government places a heavy focus on catching and punishing healthcare fraud.

If you have been charged with healthcare fraud, or if you believe you are under investigation for the crime, you need to take the charge seriously. You should seek legal help from a white-collar crime attorney who has experience protecting the rights of individuals facing healthcare fraud and other serious offenses in federal courts in Texas.

Contact Broden & Mickelsen, LLP today. We can bring more than six decades of combined criminal defense experience to your case, as well as a long record of helping clients successfully fight their charges. As Dallas healthcare fraud lawyers, we can provide a free and confidential consultation about your case.

What Is Considered Healthcare Fraud?

Healthcare fraud is defined as defrauding a healthcare benefits program or obtaining money, or other property, in the custody or care of a healthcare benefits program by false or fraudulent pretenses or promises. A healthcare benefits program includes “any public or private plan or contract under which any medical benefit, item or service is provided to any individual.”

Types of Healthcare Fraud Cases We Handle

The criminal defense attorneys at Broden & Mickelsen, LLP, have extensive experience defending clients against various healthcare fraud charges in federal court. Some of the most commonly charged types of healthcare fraud in Texas include:

Federal prosecutors can charge medical providers, patients, and others for intentionally deceiving the healthcare system to obtain unlawful benefits and payments. The FBI heads most healthcare fraud investigations involving federal and private insurance programs, but it may partner with state and local agencies in Texas. Recently, the federal government has ramped up its efforts to detect healthcare fraud related to COVID-19.

To prove conspiracy, the government must prove that two or more people reached an agreement to commit healthcare fraud. In addition, the government must prove that the defendant knew that they were doing something unlawful and willfully joined the agreement. The agreement doesn’t need to be a formal one. A person can enter such an agreement even if their role was minor

Another common allegation involves the anti-kickback statute. It criminalizes the payment of any funds or benefits designed to encourage an individual to refer another party to a federal benefits program healthcare provider. However, the statute contains a “safe-harbor provision” which allows payment if an employer pays it to an employee and there is a bona fide employment relationship between them. Factors that determine whether an employer-employee relationship truly exists include the method of payment, whether the work is part of the regular business of the hiring party, and the hiring party’s control over work hours. A violation of this offense does not require knowledge of the statute or the specific intent to violate it. Knowingly compensating someone for a referral to a federal healthcare benefits program provider such as Medicare or Medicaid constitutes a criminal violation.

An example of an arrangement involving bribery in the healthcare profession involves surgeons receiving compensation from hospitals for agreeing to operate at a facility even when the patients have private insurance. Federal prosecutors may rely on state statutes prohibiting commercial bribery and prosecute these arrangements under the Travel Act. The Travel Act prohibits interstate travel with the intent to “promote, manage, establish, carry on, or facilitate” illegal activity. The Act was primarily aimed at organized crime and, more specifically, at persons who reside in one state while operating or managing illegal activities located in another state. Still, the government has successfully prosecuted healthcare providers who pay or were paid kickbacks for medical referrals for cases involving exclusively private insurance. Consequently, practitioners should be wary of ever compensating someone for a referral.

Healthcare providers can also be charged with illegal drug distribution. Section 841(a)(1) makes it unlawful for any person to knowingly or intentionally manufacture, distribute, or dispense a controlled substance. Although medical professionals registered with the Attorney General are generally permitted to dispense controlled substances, they “can be prosecuted under § 841 when their activities fall outside the usual course of professional practice.” Notably, in federal court in Texas, the government does not need to show the distribution by a healthcare professional had no legitimate medical purpose. It is sufficient for the government to simply argue the prescription is bad medicine or outside the usual course of professional practice.

In addition to charges specifically related to healthcare fraud and improper prescriptions, the government also charges many healthcare providers with money laundering and conspiracy to launder money. Although it is unusual for healthcare providers to engage in money laundering as understood in common parlance, legally, it is extremely easy for the government to prove money laundering under the statute, 18 U.S.C. § 1956. It only requires proof the defendant engaged in a financial transaction involving the proceeds of the specified illegal activity (namely the healthcare fraud or improper distribution) and that the defendant knew the transaction was designed, at least in part, to conceal or disguise something about the transaction. Another statute, 18 U.S.C. § 1957, has less severe penalties than § 1956, and it does not require that the purpose of the transaction was to conceal. The government only needs to prove the defendant engaged in a transaction knowing it involved the proceeds of a crime.

The government has even used the statute criminalizing identity theft in healthcare fraud prosecutions. The statute, 18 U.S.C. § 1028(a), provides for a mandatory two-year consecutive sentence for a defendant that uses someone’s means of identification without lawful authority during the commission of healthcare fraud. A commonsense reading of this statute is that it applies to situations in which a defendant steals someone’s identity and, for example, falsely claims the stolen identity was a Medicare beneficiary for whom the defendant provided service. In federal court in Texas, the courts have upheld the application of this law in cases in which the healthcare provider simply engaged in fraud in relation to a patient, reasoning that because the patient did not agree to the defendant’s overbilling Medicare for the care provided, the patient’s identification was used without lawful authority.

What You Need to Know About Healthcare Fraud Penalties

The U.S. Sentencing Guidelines apply to all criminal cases, including those involving healthcare fraud. In healthcare fraud cases, the single most important factor in determining the recommended range in the federal sentencing guidelines is the loss amount. As a practical matter, the term “loss” in this context has varying interpretations.

Because Medicare refuses to pay the provider if there is any fraud concerning the claim, some courts have held that the entire billed amount constitutes an intended loss. But this is absurd when the amount the provider bills is much larger than what the contracted amount for the service is by the payor. In other words, it is common for providers to charge $10,000 for a procedure, knowing that Medicare only pays $2,500 for it. In some cases, the provider may have done a valid procedure for $2,200 but falsely billed for a more expensive $2,500 procedure. Usually, the courts have held in cases such as this that the guideline loss is the $300 difference, not the total $2,500 that was paid or even the $10,000 that the provider invoices for the procedure.

In cases involving improper prescriptions of controlled substances, the guidelines are calculated in the same manner as if the prescriber were selling the substance to addicts on the street and often increase the penalties by claiming that the healthcare professional abused “a position of trust.” Given that the federal penalties for drug distribution are extremely harsh, a healthcare provider who is convicted of improper prescribing in federal court may be confronted with a draconian sentence.

Common Healthcare Fraud Defenses

When we as healthcare fraud defense attorneys at Broden & Mickelsen, LLP, review your case, we will explore all defense strategies available to you. Some of the most common defenses against healthcare fraud charges include:

  • Unreasonable Search and Seizure – In some cases, the government’s healthcare fraud evidence may have been unlawfully obtained by investigators and prosecutors in violation of a defendant’s constitutional rights. If the evidence is suppressed, the government may have no choice but to drop the charges.
  • Insufficient Evidence – The government needs to prove your intent to commit healthcare fraud beyond a reasonable doubt. If the government lacks sufficient evidence of intent, the government cannot go forward with its case.
  • Consent – Even though a victim accused a defendant of healthcare fraud, the defendant may be able to rebut that accusation with documents showing the person consented to the treatment.
  • Compliance Programs – If you have a comprehensive compliance program in place that is aimed at preventing healthcare fraud, it may show that you had no intent to commit any form of fraud.

Dallas Healthcare Fraud Attorneys Standing Ready to Fight for You

If you are facing healthcare fraud charges in Dallas, you should not delay getting experienced legal representation on your side. The federal government works hard to prosecute these cases. You need knowledgeable Dallas healthcare fraud defense attorneys on your side who will fight back and protect your rights.

Contact Broden & Mickelsen, LLP today, and learn more about how we can help you in a free and confidential consultation.