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Are you a doctor, osteopath, physician or other type of health care worker facing charges related to health care fraud? If so, you are looking at a plethora of administrative, financial, legal and professional consequences. It behooves you to consult with an experienced Delaware criminal defense attorney handling health care fraud charges.

To discuss your case please dial (302) 744-9290 to speak with Delaware Health Care Fraud Attorney John R. Garey. Mr. Garey is a former state prosecutor who is now a defense lawyer serving the Wilmington, Newark, Middletown, Smyrna, Dover Georgetown, Seaford and Delaware beach areas.

Health Care Fraud Statistics

Health care fraud is a major government priority right now. It may be that it’s the most commonly prosecuted kind of white collar crime in federal court. The Department of Justice and the Department of Health and Human Services’s Office of Inspector General are spending tremendous resources investigating and prosecuting health care fraud cases.
According to recent studies scams against government and private healthcare insurers form by far the largest type of insurance fraud. The exact size of annual theft is unknown, and is the subject of considerable debate. Healthcare fraud likely steals tens of billions of dollars a year.

  • Healthcare expenditures in the U.S. are projected to reach $3.2 trillion in 2015 b or about $10,000 per person.
  • Medicare spending is projected to reach $616.8 billion in FY 2014.
  • Financial losses from healthcare fraud are amount to tens of billions of dollars annually.
  • Global healthcare fraud and error losses have risen 25 percent to 6.9 percent total since 2008;
  • This means $487 billion lost in a year b one-fifth of total U.S. healthcare expenditures for 2011; and
  • Reductions in fraud and error losses of up to 40 percent are possible within one year b freeing up to $195 billion globally.

Medicare & Medicaid Fraud

Medicare is designated as a high-risk program because of its size, complexity and vulnerability to improper payments.

  • More than $27.8 billion has been returned to the Medicare Trust Fund since the Health Care Fraud and Abuse Control Program was created in 1997;
  • Anti-fraud efforts recovered $3.3 billion in taxpayer dollars in FY 2014; and
  • $7.70 was returned for every anti-fraud dollar invested. This is about $2 higher than the average ROI since 1997.B Itbs also the third-highest ROI.

Medicare Strike Force
Defendants collectively have billed Medicare more than $7 billion since Medicare Strike Force operations began in 2007. During this time, the Strike force has:

  • Lodged 1,285 criminal actions;
  • Charged more than 2,300 defendants; and
  • They’ve collectively billed Medicare more than $7 billion. (U.S. Department of Health and Human Services, June 2015)

Recoveries & improper payments

  • DOJ and HHS healthcare fraud and prevention efforts recovered nearly $3.3 billion in FY 2014;
  • DOJ has recovered more than $15 billion in healthcare-fraud cases over the last five years; and
  • The average prison sentence was more than four years for Medicare Strike Force cases in FY 2014. Some prosecutions in recent years earned sentences of up to 50 years. (Federal Bureau of Investigation, June 2015)
  • Nearly $80 billion of improper Medicare and Medicaid payments were made in FY 2014;
  • $60 billion involved improper Medicare payments. That’s about 10 percent of the $603 billion spent to provide coverage for 54 million Medicare beneficiaries last year;
  • The $60 billion figure also is the largest portion of the $124.7 billion in improper payments across all federal programs; and
  • $17.5 billion involved improper Medicaid payments. That’s about six percent of the $304 billion spent on Medicaid.
  • Improper payments for home healthcare coverage increase from 17.3 percent in FY 2013 to 51.4 percent in FY 2014.

These are staggering statistics and they reiterate the serious, and very costly, nature of health care fraud. If you are facing health care fraud in Delaware contact Wilmington Health Care Fraud Attorney John R. Garey to discuss your rights and how he can protect them.

Consequences Of Federal Health Care Fraud

If you provide health care services and you’re under investigation for health care fraud, you have two big concerns.
First, these cases are often prosecuted in federal court. If you’re prosecuted in a federal criminal case you can go to a federal prison. Most people think that prison time is the most serious consequence of a health care fraud case – and for good reason.
Second, you can lose your ability to bill a federal health care program. For most medical providers, not taking federal health care payments is just not viable. Being a person suspended from Medicare can be career death. It’s a serious consequence for anyone who practices medicine and is caught up in a federal health care fraud case.

The Origin Of Health Care Fraud Cases

These cases start a few different ways.
One way is with the filing of a lawsuit under the False Claims Act. These suits – which are also called qui tam suits – are filed when someone learns about a company submitting false claims to the federal government for payment. That person can then bring a lawsuit, which is forwarded to the federal government. If the suit is successful, the person who brought it can be paid a significant amount of money as a percentage of whatever the federal government recovers.
Another way for these cases to start is when the OIG at Health and Human Services learns about a practice that’s billing the federal government – usually Medicare – and the OIG thinks that there’s something odd and possibly fraudulent about how these claims are being submitted. They sometimes bring in the FBI, and sometimes they don’t. These cases then look a whole lot like normal criminal investigations.

Health Care Fraud

The most frequent kind of health care fraud involves false statements in bills submitted to Medicare. There are generally two ways this happens.
First, medical providers bill for procedures that weren’t done. So, for example, there have been cases where Medicare is billed for fake patients – people who never received medical care at a facility. Or for patients who hadn’t come in for a procedure in a long time.
The bottom line is that these are claims submitted to the federal government for procedures that were never done.
Second, sometimes medical providers will use a code for a procedure that pays more than the code for the procedure that was actually done. This is called upcoding.
To see how this works, suppose, for a second, that if a dermatologist removes a skin spot that’s bigger than a quarter that’s one code, which pays more than a procedure to remove a smaller spot. If a dermatologist systematically submits invoices for the procedure to remove a large spot when she only performs the procedure to remove a small spot, that could be fraud.
A big issue in these cases is who was responsible for the false claims. In some cases, some one in the practice who was responsible for the billing took initiative and presented the false claims. This seems more likely to happen when that person is paid a percentage of revenue from the practice as a part of compensation.
In other cases, the government has proof that the medical professional knew about and participated in the fraud. In those cases, the doctor is the person in the government’s cross hairs.

Fraud Resources

Please see our different pages regarding fraud by visiting the links below as we handle all fraud cases including:
Check Fraud
Bankruptcy Fraud
Immigration Fraud
Medicare Fraud
Our experienced Delaware health care fraud lawyers will do everything needed to protect your rights, your professional credentials and your professional reputation.

Let A Newark Health Care Fraud Attorney Help

Please feel free to contact Delaware Health Care Fraud Lawyer John R. Garey to discuss your case. His Dover criminal law office can be reached atB (302) 744-9290. Mr. Garey serves all 3 Delaware counties: New Castle County (NCCO), Kent County and Sussex County.