Health care fraud is the falsifying of claims for health care services to the state government or the federal government. For example, if a doctor submits a claim to MassHealth, the state Medicaid program, asking for reimbursement for services provided to a low income individual, but overstates the amount of the services, or intentionally miss-classifies a patient as low income, or orders medically unnecessary tests, that would constitute health care fraud. In addition, if a doctor receives kickbacks for prescribing certain medications or employs unqualified personnel, he or she commits health care fraud. Alternatively, a consumer commits health care fraud when he or she sells medication on the black market that was provided through a prescription covered by Medicaid.
Massachusetts law enforcement have begun to investigate and prosecute health care fraud much more aggressively over the past few years. The Medicaid Fraud Division, within the Attorney General’s office, is responsible for investigating health care providers for fraud. The Division usually begins investigations in response to complaints by private citizens or employees of health care providers, in conjunction with law enforcement officers from local, state and federal agencies. Where an investigation uncovers evidence of fraud, the Division is also responsible for prosecuting suspected violators.
To prove an individual guilty of health care fraud, the prosecutor generally must prove three elements beyond a reasonable doubt:
First, the prosecutor must prove that the defendant knowingly made a false or misleading statement. In layman’s terms, this means that the defendant intentionally lied in order to gain something for him or herself. An innocent mistake by the defendant cannot qualify as fraud.
Second, the prosecutor must prove that the defendant’s statement was made in connection with the delivery or payment of health care services.
Third, the prosecutor must prove that the defendant’s false statement was material. This means that the defendant’s false statement must be important, or has some bearing on the outcome of the payment made to the defendant, or of the defendant’s claim for services.
Health care fraud is a serious offense and can result in both civil and criminal penalties, at both the state and federal levels. If you are convicted of health care fraud under state law, you face a 5-year sentence in state prison. Under federal law, a conviction for health care fraud carries a 10-year sentence. In addition, fines are usually imposed of up to $250,000 per offense.
Health Care Fraud Lawyers at Altman & Altman, LLP
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