Las Vegas Federal Health Care Fraud Defense Attorney
Health care fraud is a federal offense that involves knowingly and willfully defrauding a health care benefit program, such as Medicare, Medicaid, or private insurance, to receive unauthorized payments or benefits. Charged under 18 U.S.C. § 1347, health care fraud can encompass a wide range of illegal activities, including billing for services not provided, upcoding, kickbacks, and falsifying patient records. Federal authorities, including the Department of Justice (DOJ) and the Department of Health and Human Services (HHS), aggressively prosecute health care fraud cases due to the significant financial harm they cause to public and private insurance programs.
At Hofland & Tomsheck, attorney Josh Tomsheck, a Nationally Board Certified Criminal Lawyer, has extensive experience defending individuals and health care providers accused of health care fraud. If you are facing federal charges for health care fraud, it is essential to have a skilled defense attorney who understands the intricacies of federal health care laws and can build a strong case to protect your rights and livelihood.
What Is Health Care Fraud?
Health care fraud, as defined under 18 U.S.C. § 1347, involves schemes to defraud any health care benefit program, including federal programs like Medicare and Medicaid, or private insurance plans. The statute criminalizes both individual and organizational conduct that results in fraudulent payments or benefits. Some of the most common forms of health care fraud include:
Billing for Services Not Provided: This occurs when a health care provider submits claims for medical services, treatments, or procedures that were never actually performed.
Upcoding: A health care provider charges for a more expensive service than the one actually provided to receive higher reimbursement from an insurance company or federal health care program.
Kickbacks: Offering, paying, soliciting, or receiving something of value (such as money or gifts) in exchange for patient referrals, services, or prescriptions that are paid for by a federal health care program.
Unnecessary Medical Procedures: Performing or billing for unnecessary medical procedures, tests, or treatments that were not medically necessary but were performed to increase profits.
Falsifying Patient Records: Altering medical records or falsifying patient information to obtain payment for services that were not provided or were not covered by insurance.
Health care fraud can be committed by a wide range of individuals, including doctors, nurses, hospital administrators, pharmacists, and even patients who make false claims for reimbursement. These cases are often complex and involve detailed audits, medical records, and billing documentation.
Case Law and Legal Precedents for Health Care Fraud
Several important court cases have shaped how health care fraud is prosecuted under federal law. In United States v. Rutgard, 116 F.3d 1270 (9th Cir. 1997), the Ninth Circuit upheld the conviction of a physician for submitting fraudulent Medicare claims, despite the defense's argument that the claims were the result of a misunderstanding rather than intentional fraud. This case set a precedent that health care providers can be held liable for submitting false claims even if the fraudulent activity was unintentional or part of a complex billing system.
In Universal Health Services, Inc. v. United States ex rel. Escobar, 579 U.S. 176 (2016), the Supreme Court ruled that health care fraud claims can be brought under the False Claims Act if a provider knowingly submits claims for services that do not meet federal standards, even if the claims are not explicitly false. This case expanded the scope of health care fraud prosecutions by allowing the government to pursue cases where claims were technically correct but involved misrepresentations about the quality or nature of the services provided.
Another significant case is United States v. Greber, 760 F.2d 68 (3d Cir. 1985), where the court held that the Anti-Kickback Statute prohibits payments made to induce referrals for services covered by federal health care programs, regardless of whether the payments were also for legitimate services. This case reinforced the broad application of the Anti-Kickback Statute in health care fraud cases.
Penalties for Health Care Fraud
Health care fraud is a felony offense under federal law, and the penalties for violating 18 U.S.C. § 1347 can be severe, particularly in cases involving large-scale fraud or significant financial losses. The penalties for health care fraud include:
Fines: A conviction for health care fraud can result in substantial fines, often ranging from tens of thousands to millions of dollars, depending on the amount of fraudulent claims submitted and the financial harm caused to health care programs.
Imprisonment: The statutory maximum penalty for health care fraud is up to 10 years in federal prison. However, if the fraud results in serious bodily injury to a patient, the maximum penalty increases to 20 years. In cases where the fraud results in a patient's death, the defendant may face life in prison.
Restitution: Defendants convicted of health care fraud are typically required to pay restitution to the victims, including federal health care programs and private insurance companies. Restitution can include the full amount of fraudulent claims paid to the defendant, as well as any additional financial losses incurred by the victims.
Forfeiture: In addition to fines and imprisonment, defendants convicted of health care fraud may be required to forfeit any property or assets obtained through the fraudulent scheme, including bank accounts, real estate, or other valuable assets.
The U.S. Sentencing Guidelines provide an advisory sentencing range for health care fraud cases, considering factors such as the amount of financial loss, the number of fraudulent claims, and the defendant's role in the scheme. Judges generally follow these guidelines but retain discretion to impose sentences based on the specific circumstances of the case.
Federal Investigations and Health Care Fraud Charges
Health care fraud cases are typically investigated by federal agencies such as the Federal Bureau of Investigation (FBI), the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS), and the Department of Justice (DOJ). These investigations often involve detailed reviews of medical records, billing statements, insurance claims, and interviews with patients and employees.
In many cases, health care fraud investigations are initiated through whistleblower claims under the False Claims Act or referrals from insurance companies that detect irregular billing patterns. Federal health care fraud task forces, such as the Health Care Fraud Prevention and Enforcement Action Team (HEAT), also play a key role in investigating and prosecuting large-scale fraud schemes.
If you are under investigation for health care fraud, it is essential to seek legal representation as early as possible. Federal authorities have significant resources to build a case, and early intervention by an experienced attorney can help protect your rights and avoid potential legal pitfalls during the investigation process.
Defenses Against Health Care Fraud Charges
At Hofland & Tomsheck, we take a strategic approach to defending clients against health care fraud charges, analyzing every aspect of the case and challenging the government's evidence. Common defenses against health care fraud charges include:
Lack of Intent: One of the key elements of health care fraud is intent. If the defendant did not knowingly and willfully engage in fraudulent conduct, this can serve as a defense. For example, billing errors or administrative mistakes may not rise to the level of criminal fraud.
Good Faith: In some cases, health care providers may have acted in good faith when submitting claims, believing that the services provided were medically necessary or covered by insurance. If the defendant relied on the advice of billing professionals or consultants, this can be used as a defense.
Challenging Evidence: Health care fraud cases often rely on extensive documentation, including medical records, billing statements, and insurance claims. By challenging the accuracy of this evidence or raising doubts about the credibility of key witnesses, we can weaken the government's case.
Statute of Limitations: In some cases, health care fraud charges may be barred by the statute of limitations if too much time has passed since the alleged fraudulent activity occurred. The statute of limitations for health care fraud is typically six years, but this may vary depending on the specific facts of the case.
Sentencing Guidelines for Health Care Fraud
Federal sentencing for health care fraud is governed by the U.S. Sentencing Guidelines, which provide an advisory range based on several factors:
Amount of Financial Loss: Larger fraud schemes that result in significant financial losses to Medicare, Medicaid, or private insurance companies generally result in harsher penalties.
Number of Fraudulent Claims: The number of false claims submitted can impact the severity of the sentence, with larger schemes involving hundreds or thousands of claims typically resulting in longer prison terms.
Harm to Patients: In cases where health care fraud results in harm to patients, such as unnecessary surgeries or improper treatment, the sentence may be enhanced under the guidelines.
Judges consider the guidelines when determining sentences but have discretion to impose sentences based on the circumstances of the case. In large-scale health care fraud cases, sentences can be significantly enhanced.
Why Choose Josh Tomsheck for Your Health Care Fraud Defense
Health care fraud cases are complex and often involve detailed audits, medical records, and financial documentation. Having an experienced defense attorney is crucial to navigating the complexities of federal law and protecting your rights. Josh Tomsheck is a Nationally Board Certified Criminal Lawyer with a proven track record of defending clients against serious federal charges, including health care fraud.
As a former prosecutor, Josh knows how the government builds its case and can anticipate the prosecution's strategies. He develops tailored defense strategies designed to challenge the government's evidence, discredit witnesses, and negotiate favorable outcomes for his clients. At Hofland & Tomsheck, we provide personalized, aggressive defense for clients facing federal health care fraud charges.
Schedule Your Free, Confidential Consultation Today
If you are facing federal health care fraud charges or are under investigation by federal authorities, contact Hofland & Tomsheck today to schedule a free, confidential consultation with Josh Tomsheck. We offer flexible consultation options, including in-person meetings, phone consultations, and Zoom sessions.
Call us at (702) 895-6760, or visit our office at 228 S. 4th Street, First Floor, Las Vegas, NV 89101. Let us help you protect your rights and build a strong defense against federal health care fraud charges.
