Understanding the Criminal Justice System
In past decades, the U.S. government took a “reactive” approach to health care fraud – something that has changed in recent years, according to Assistant Attorney General Leslie R. Caldwell. Addressing the American Bar Association, Ms. Caldwell stated that the federal government has “come a long way since those days.”
In previous years, Ms. Caldwell said, the Criminal Division’s Fraud Section would wait for referrals of suspected illegal activity – typically from the Centers for Medicare and Medicaid Services – before taking action in a suspected health care fraud case. In 2007, however, the Criminal Division created a task force that specifically targets Medicare fraud. In 2014 alone, the task force charged over 350 defendants with Medicare fraud.
The Department of Justice has also begun to investigate health care fraud more aggressively. In May 2015, it announced that 16 hospitals agreed to pay $15.69 million in penalties for violations of the False Claims Act.
Sometimes referred to as “qui tam” or “Lincoln Law” cases, the False Claims Act allows a private individual to alert federal authorities to cases of fraud against the government. The statute is occasionally referred to as the Lincoln Law because the Act was passed in response to federal contractors taking advantage of the Union military and the federal government during the Civil War. Individuals who alert the government to fraud are eligible to receive a portion of the funds recovered, which gives them an incentive to report fraudulent activity.
According to the Department of Justice, the hospitals in question knowingly submitted claims for psychotherapy services that failed to qualify for Medicare reimbursement for a number of reasons.
Health care regulations, particularly Medicare rules, can be extremely complex. Determining coverage isn’t always straightforward. Honest people make mistakes. Most health care professionals are compassionate people who truly want to help others. Unfortunately, false accusations do happen. A health care fraud allegation can result in federal indictments, DEA raids, state licensing sanctions, expulsion from the Medicare program, a damaged reputation, and loss of professional licensure. Even an accusation can have severe personal and professional consequences. If you have been accused of health care fraud, it’s critical to obtain experienced legal representation as soon as possible.
