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What’s at Risk When You Get Accused of Health Care Billing Fraud?

Compared with armed robbery, which victimizes an individual, or embezzlement, which involves pocketing your employer’s resources, health care fraud probably doesn’t seem like a serious criminal allegation. After all, the victims of health care fraud are either massive insurance companies or, in some cases, the government.

Those who work at a medical facility or who operate a medical practice have to constantly struggle to keep their revenue higher than operating expenses. With inflation wreaking havoc on the cost of standard supplies and utility expenses, medical practices may find that their profit margin has started to shrink.

Although employing creative billing practices could increase your profit margin, doing so comes with a lot of risks. You could face accusations of health care fraud.

Federal law could lead to prosecution and financial obligations

Under the False Claims Act, anyone who participates in fraudulent billing practices or benefits from them could find themselves implicated in a health care fraud conspiracy. If the Justice Department brings charges against you or if a coworker initiates a qui tam lawsuit on behalf of the government, you could have a lot at risk.

A conviction for health care fraud could cost you your professional license, lead to massive fines and result in incarceration.

The False Claims Act allows the federal government to seek up to three times the amount that they paid in compensation from a convicted defendant. You could be subject to tens or hundreds of thousands of dollars in repayment obligations if you plead guilty or get convicted of health care fraud involving federal insurance programs.

How do you defend against fraud allegations?

One of the reasons many people plead guilty when facing charges under the False Claims Act is out of fear of the worst-case penalties if they go to court. However, unless you have an airtight plea bargain that guarantees reduced penalties, the consequences you face could still be the maximum penalties at the discretion of the judge overseeing your case.

There could be multiple ways to defend against fraud allegations. You might prove that you simply did what your supervisors trained you to do or produced documents that raised a question about whether fraud actually occurred.

A thorough review of the evidence against you will likely be necessary to determine the best strategy, but you can potentially fight back against health care fraud allegations. Mounting a rigorous defense may be the only way to avoid criminal penalties and massive financial obligations triggered by health care fraud.