Understanding Healthcare Fraud

healthcare fraud

What Is Health Care Fraud?

Under 18 U.S. Code § 1347, healthcare fraud is legally defined as knowingly and willfully executing a scheme or artifice:

  • to defraud any healthcare benefit program or
  • to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program.

Penalties of Conviction for Healthcare Fraud

The legal repercussions of being convicted for healthcare fraud are indeed severe and can significantly impact an individual's personal, professional, and financial life. The most severe punishment includes up to 10 years of imprisonment. However, if the fraudulent act results in serious bodily harm, the imprisonment term can extend up to 20 years.

Apart from the primary charge of healthcare fraud, there are several other offenses that could be leveled concurrently, all of which carry severe prison terms. These include:

  • Wire fraud, which can result in a maximum of 20 years of imprisonment.
  • Violation of the False Claims Act, which can result in a maximum of five years of imprisonment per count. A conviction on multiple counts could lead to a life sentence.
  • Money laundering, which carries a maximum penalty of ten years in prison.
  • Conspiracy to commit money laundering, which is punishable by up to 20 years in prison.
  • Conspiracy to commit healthcare fraud, which is punishable by up to 20 years in prison.
  • Anti-Kickback Statute violations, which arepunishable by up to five years in prison.

In addition to imprisonment and criminal fines, those convicted of health care fraud can face civil fines. Healthcare professionals can also lose their license and DEA registration, and they can be:

  • Forced to let get of staff privileges.
  • Lose the right to be paid for outstanding invoices.
  • Excluded from inclusion in Medicare and Medicaid programs.

Outside of the federal penalties, healthcare fraud can also lead to criminal convictions in Florida. For instance, a person may face false and fraudulent insurance claims charges, which are considered a felony of the third degree (see Florida Statute § 817.234), or Medicaid provider fraud, which is also a third-degree felony.

Common Types of Health Care Fraud

Several types of activities can fall under health care fraud, with some being more prevalent than others. Below are some of the most common types of health care fraud:

  • Billing for services not rendered. This involves healthcare providers billing insurance companies for services they didn't provide.
  • Misuse of insurance. Here, an individual uses someone else's insurance information to receive healthcare benefits.
  • Upcoding of procedures. In this case, a healthcare provider falsely inflates a patient's diagnosis to a more severe condition that requires more expensive treatments.
  • Double billing. This occurs when a provider bills more than once for the same service.
  • Bogus marketing. This involves selling unproven and ineffective drugs or medical devices under false claims.
  • Forgery. This includes altering or fabricating medical records, prescriptions, or other documents.
  • Illegal kickbacks. This happens when healthcare providers accept bribes or rebates for referring patients to specific medical facilities or for prescribing certain drugs.
  • Unbundling. This type of fraud occurs when medical providers submit multiple bills for a single service provided.
  • Healthcare professional impersonation. This type of fraud occurs when a person without a medical license provides and bills for healthcare services and/or equipment.
  • Fraud involving prescription medication. In some cases, a person may visit multiple service providers to get a prescription for drugs (that are controlled substances or to get a prescription from an unethical office.

Health Care Fraud Cases

Here are some real-life examples of health care fraud cases:

The Case of the Nurse Practitioner

In September 2023, a Florida nurse practitioner was convicted of one count of conspiracy to commit health care fraud, one count of wire fraud, four counts of health care fraud, and three counts of making false statements concerning health care matters. Her sentencing is not until December 2023, but she is facing ten years for each health care fraud charge, 20 years for the conspiracy charge, and five years for each false statement offense.

According to court documents and evidence presented, Nurse Hernandez signed thousands of documents for unneeded genetic tests and orthotic braces, which led to over $200 million in fraudulent Medicare bills. To help with the scheme, telemarketers would contact Medicare beneficiaries. These companies persuaded them to request orthotic braces and genetic tests.

Subsequently, pre-filled orders for these items were sent to Hernandez for her signature, implying that she had examined or treated these patients. However, the reality was starkly different; many of these patients had never interacted with Hernandez.

Hernandez's fraudulent activities peaked in 2020 when she ordered more cancer genetic tests for Medicare beneficiaries than any other healthcare provider in the country, including specialists such as oncologists and geneticists. She then proceeded to bill Medicare, falsely claiming she had conducted complex office visits with these patients. Her fraudulent claims even included instances where she billed for more than 24 hours of "office visits" in a single day.

Hernandez personally amassed $1.6 million from this scheme. She used this money to find a lavish lifestyle and treated herself to luxury cars, jewelry, home renovations, and travel.

The Case of the Home Health Fraud & Money Laundering Scheme

In October 2023, a Miami jury convicted two Floridians, Karel Felipe and Tamara Quicutis, of conspiracy to commit health care fraud and wire fraud and conspiracy to commit money laundering. This conviction was tied to their part in a Medicare fraud case that led to an excess of $93 million of fraudulent home health therapy service bills.

The two are facing 20 years (maximum) for each conspiracy charge. Their sentencing hearing has been scheduled for January 2024.

Based on what was revealed in court, Felipe and Quicutis conspired with a group of others to submit fraudulent bills to Medicare from three Michigan home health companies. Others in the group also used contacts in Cuba to sign the Medicare enrollment documents and act as the owners of the home health agencies.

Felipe, Quicutis, and their co-conspirators then used shell companies and multiple bank accounts to launder the money they received from Medicare and convert it into cash at ATMs and check-cashing stores in the Miami area.

The Case of the Dallas Doctors

On November 20th, 2023, the news about the arrest of doctors Desi Barroga and Deno Barroga broke. These two doctors were arrested and charged because they allegedly charged around $12 million for unrendered services.

They are each facing trial for the following charges: conspiracy to commit healthcare fraud, unlawful distribution of controlled substances, and five counts of healthcare fraud. If convicted, both doctors face up to ten years of imprisonment for each count of health care fraud and up to 20 years for distribution of a controlled substance.

According to available case information, the duo used their pain management clinic and privileges as medical professionals to give patients controlled substances unnecessarily. Patients would submit insurance claims, saying that the doctors gave them dozens of corticosteroid injections. However, in reality, they were giving patients oxycodone, hydrocodone, and morphine.

Get Legal Counsel

Facing charges for white-collar crimes, such as healthcare fraud, calls for a robust and personalized defense strategy—one that considers the unique circumstances of each case. The Law Office of Jody L. Fisher is well-equipped to aid clients in formulating such strategies, backed by an experienced legal team adept at handling complex legal matters.

In addition to building a solid defense, the Law Office of Jody L. Fisher places significant emphasis on client communication and support throughout the legal process. We believe that keeping clients informed at every stage can alleviate some of the stress associated with legal proceedings. We also value the input of their clients, understanding that they are not just cases but individuals with their own perspectives and insights that could prove invaluable to the defense.

Get started on your defense case today by calling (352) 503-4111.

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