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Health Care Fraud Prosecutions – Upcoding and Overbilling

Health Care Fraud Cases

There are a variety of “health care fraud” activities that cause physicians and their staff to fraudulently obtain monies from insurance companies and/or government programs that involve doctor visits, chiropractic care, medical procedures, prescription medication, and medical supplies. The focus of this article is criminal investigations and prosecutions for activities related to health care, which are fraudulent.

Fraudulent activities could be misrepresentations by physicians, chiropractors, nurse practitioners, nurses, medical staff, hospital administrators, pharmacists, and patients. These representations could be: misrepresentations on prescriptions for medication (controlled drugs), wrong or improper billing for reimbursement to doctors’ offices, performing unnecessary procedures, claiming procedures performed that were not performed, and prescribing and ordering unnecessary supplies.

Upcoding and Overbilling

Improper billing and claiming procedures performed that were not, are commonly referred to as “upcoding,” meaning that a medical staff person will claim a more intense and more expensive code on claims for reimbursement by insurance companies and/or Medicare or Medicaid. The reason for upcoding is to either receive a reimbursement for work not performed, or to receive a reimbursement for a more expensive procedure that sends more money to the doctor than normally would have been received for the work that was performed.

The same applies to overbilling for services or supplies. This means that the services claimed for reimbursement were either not performed, supplies were not received and given to the patient, and/or the reimbursement claimed was for services not given or performed.

What to Do If You Believe You Are a Target of the Investigation

Hire an experienced federal defense attorney who knows the U.S. Attorney’s / Department of Justice’s prosecution strategies. That is, an experienced federal attorney who has worked many of these cases is best suited to defend you.

The well-experienced federal defense attorney can learn much from the federal prosecutor’s office about the evidence that they believe they have against you. Your experienced attorney can also delay potential formal charges by meeting with prosecutors and making presentations of potential evidence in your favor.

Defend Your Position

A well-experienced federal attorney will work with you to try to prove to the U.S. Attorney or the U.S. Department of Justice attorney that the government’s allegations are wrong or overstated. A pro-active position can serve you well in order to buy time to learn as much as possible about the evidence that the government is holding. Then, you can act in order to try to prevent a grand jury from bringing formal charges against you.

Pro-Active When Time Counts

You want to try to get as much favorable evidence to the prosecutor as possible, or depending on the government’s stance, enough to initially determine if the prosecution is willing to seriously consider your evidence, and therefore, not charge you. If the prosecution is determined to move forward with a case against you no matter they evidence presented or verbalized, then you may want to hold it later until hearings or a trial. A former federal prosecutor/experienced federal defense attorney can guide you to make this decision.

Call Attorney John Teakell

Mr. Teakell was a federal prosecutor for many years, and he has years of experience defending people who have been charged, or who are under investigation, for health care fraud charges and other federal cases.

Have a challenging case? Get a free consultation by our experts today!