If you’re in the healthcare field, you entered a noble profession that takes dedication and compassion, but if you’re facing a healthcare fraud charge, you may be feeling as if all your hard work is going down the drain. It’s important to keep in mind, however, that being charged with healthcare fraud is not the same thing as being guilty of healthcare fraud.
The most important thing you can do at this juncture is turn to an experienced Round Rock criminal defense attorney for the professional legal guidance you need.
Healthcare Fraud Comes in Many Forms
There are a wide range of healthcare fraud charges out there, and knowing what you’re up against can help you build a stronger defense.
Billing for Services Not Rendered
Billing for services, treatments, or procedures that were never performed is a very common form of healthcare fraud. This often involves tampering with patient records, such as falsifying dates or taking over patient identities, to generate bills that are not connected to actual medical care.
This can include billing for patients who are no longer active at the medical facility or who may no longer be alive. This not only cheats insurance companies out of funds that they pay in good faith, but can also lead to higher out-of-pocket payments for the patients themselves.
In addition, it affects patients’ medical records, which can go on to affect their future healthcare needs and associated costs. For example, when a patient is fraudulently charged for a yearly exam, it means that the yearly exam that they actually receive, potentially at a different healthcare facility, likely won’t be covered by their health insurance.
Upcoding and Unbundling
Unbundling is a form of upcoding, which is a common form of healthcare fraud. Let’s take a closer look.
Upcoding
Upcoding refers to billing for a medical service that is more costly than the service that was actually provided. For example, if you go to the doctor for a routine check-up but your insurance provider is billed for a thorough exam that is much more expensive, it’s a form of upcoding that can qualify as healthcare fraud.
The medical facility is reimbursed at a higher rate, and the insurance company ends up paying more than it should, while you could also pay more out of pocket. When upcoding is done intentionally, it qualifies as healthcare fraud and can lead to criminal charges.
Healthcare billing is extremely complicated, and the codes used to identify services describe not only the extent of the medical procedures performed but also the cost. Simply swapping out codes associated with more involved and more expensive procedures for those that are less involved and less costly is a means of fraudulently increasing a medical facility’s income.
Unbundling
Unbundling is a specific form of upcoding that involves separating bundled procedures that are billed together into individual codes in order to charge more overall. For example, incisions and closures are generally billed together, but breaking them down into separate charges leads to a higher grand total.
Prescription Fraud
The charge of prescription fraud relates to actions such as overprescribing medications, forging prescriptions, and diverting drugs for illegal sale. Prescription fraud is considered the origin of the opioid crisis in the United States, which means it has put many, many people at risk of life–threatening addictions and other very serious health concerns.
Writing False Prescriptions
Taking a doctor’s prescription pad and using it to write fake prescriptions for opioids or any drug for oneself or for someone who doesn’t exist is a prime form of healthcare fraud that can be committed by someone outside the healthcare profession.
Since late 2024, most states in the nation have required e-prescriptions for all controlled substances, and Texas is among them.
It’s important to point out here, however, that there are exceptions when it comes to e-prescriptions. For example, if you use a pharmacy that isn’t equipped to handle electronic prescriptions, you have a strong case for requesting a paper prescription. You may also want to shop around to find the best price, which can also require a paper prescription.
The cost of medicine can be extremely high, and finding the lowest rate isn’t just a means of saving a few dollars but could also be a patient’s only way to afford the medication at all. Those who write prescriptions are called upon to balance the convenience of e-prescriptions with their patients’ needs, including in relation to cost.
Posing as a Doctor
Posing as a doctor is another kind of prescription fraud. This generally involves either posing as a doctor calling in a prescription on the phone or pretending to be calling from a doctor’s office to call in a prescription. Again, prescriptions for controlled substances must be sent electronically now, but some Texas doctors have waivers.
Altering Prescriptions
Another form of healthcare fraud that’s often perpetrated by those outside the field is altering prescriptions. This translates to altering an actual prescription in order to receive more pills, more refills, or higher doses of the drug in question.
State Laws against Prescription Fraud
Texas has several laws on the books that are designed to address prescription fraud. These include each of the following:
A prohibition against sharing prescription forms or otherwise gaining illegal access to prescription forms
A prohibition against the possession of prescription medications with the intention of delivering them without a valid prescription
A prohibition against obtaining prescription medications without a prescription, such as buying them on the street or off of someone else
Red Flags
Prescription fraud can take any number of forms – many of which are difficult to spot. There are, however, some red flags that the authorities watch out for, including:
Billing that is inconsistent, such as when the billing bears little relation to the care the patient received
Billing in which there are frequent code changes, such as when diagnosis codes change without any basis for doing so
Billing for procedures that weren’t necessary
Billing that piles on multiple charges that all relate to similar procedures
The False Claims Act
Upcoding in its various forms is addressed by the False Claims Act, which is a federal law that allows the government to go after damages from anyone who defrauds federal healthcare programs, such as Medicare or Medicaid. A conviction can lead to serious fines and penalties as well a federal prison sentence.
False Diagnoses
False diagnoses and unnecessary treatments tend to go hand in hand. Diagnosing a patient’s illness is a challenging medical process that sometimes requires trial and error, and any medical professional can make a mistake when it comes to diagnosing their patients. If this weren’t the case, we’d all experience optimal health outcomes all of the time, which is far from realistic.
However, when doctors intentionally misdiagnose patients in order to justify the performance of costly tests, procedures, or treatments that simply aren’t needed, it leads to serious financial losses, puts the involved patients at risk of being harmed, and is against the law.
A Prime Texas Example
In 2020, a Texas rheumatologist was found guilty by a federal jury for the role he played in a healthcare fraud scheme that brought in $325 million. The fraud involved falsely diagnosing patients with chronic diseases, then treating them with harsh and harmful prescription medications that were based on their false diagnoses.
Among those falsely diagnosed were elderly patients, very young patients, and people with disabilities.
A Lavish Lifestyle
The doctor in question was accused of using his fraudulent earnings to fund a lavish lifestyle. This was accomplished through money laundering—which is a separate crime—via a money exchange house in Texas, which he then kept in various accounts maintained by Mexican financial institutions. The scheme dated back to 2000.
Kickbacks and Bribes
Kickbacks refer to paying money – or other benefits – for business referrals when doing so is against the law, which is the case in the healthcare profession in Texas and the rest of the nation.
In fact, Texas has an anti-kickback statute that makes it illegal to entice medical professionals and facilities to prescribe their drugs or to use their medical equipment or supplies when billing a federal program, such as Medicare or Medicaid.
Federal laws also prohibit medical professionals from accepting what amounts to bribes, whether the related billing affects federal or private health insurance programs.
There was a time when pharmaceutical companies shamelessly hawked their wares by buttering up medical professionals with what amounted to kickbacks to persuade them to prescribe their products, when comparable medications may have been on the market at a reduced price point. While this was very common back in the 1990s, the laws have tightened up considerably.
If You Are Facing a HealthCare Fraud Charge
If you are facing a healthcare fraud charge, the first order of business is working closely with a formidable Round Rock criminal defense attorney who has reserves of experience successfully guiding these challenging cases toward advantageous outcomes that support their clients’ professional futures.
Related Benefits
Having professional legal representation in your corner comes with all the following primary benefits:
Skillfully guiding you through the criminal justice process and helping to ensure that you avoid the kind of mistakes that can make it more difficult to effectively defend yourself.
Gathering all the evidence that relates to your case, including everything that the prosecution has – some of which may prove to be in your favor – and ably compiling it into a solid defense that the state will have a difficult time refuting.
Knowledgeably negotiating with the prosecution in a focused attempt to have the case against you dropped altogether or to have the charge against you and the attendant fines and penalties reduced significantly, when making a plea deal is deemed advantageous.
Being well prepared to take your case to court and leaving no stone unturned in their tireless efforts to effect a beneficial case resolution on your behalf, when going to trial is deemed the right course of action.
Defense Strategies
While the healthcare fraud case you’re facing will be specific to the unique circumstances involved, most defense strategies fall into basic categories.
It Wasn’t You
This defense is that the prosecution simply has the wrong person. The state or federal government may have a healthcare fraud case, but you’re not the person who committed the crime.
You Lacked the Necessary Element of Intent
To commit healthcare fraud, you must have intended to defraud your victim or victims. You may have made a mistake, but if you lacked the necessary intent, you can’t be convicted of healthcare fraud at either the state or federal level.
There Is Insufficient Evidence against You
If the prosecution doesn’t have enough evidence to prove your guilt beyond a reasonable doubt, they can’t get a conviction. Beyond a reasonable doubt in this context means that there is no alternative explanation that is reasonable, which, in turn, means that a considerable amount of evidence is needed.
You Were Entrapped
If you were induced, coerced, or provoked by a law enforcement official to commit healthcare fraud in a situation in which you otherwise would not have, it’s called entrapment, and it can hold up as a strong defense in your healthcare fraud case.
Don’t Wait to Discuss Your Case with an Experienced Round Rock Criminal Defense Lawyer
Brett Pritchard at The Law Office of Brett H. Pritchard – proudly serving Round Rock, Texas, for two decades – is a resilient criminal defense attorney who is well known for the skilled legal guidance he provides and for the advantageous outcomes he achieves.
We’re here for you, too, so please don’t wait to contact or call us at 254-781-4222 and schedule your free consultation today.