Health Care Fraud

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

Contact our Boston/Cambridge attorneys for a free initial consultation if you or a loved one is being charged with health care fraud. You are entitled to the best legal defense possible. Altman & Altman can deliver that defense for you. Please call 617.492.3000 or 800.481.6199 (toll free) or contact us online to request your free case evaluation.

Client Reviews
★★★★★
Dear Sam, I can not thank you enough for your expertise in the handling of Chris's case as well as your sensitivity and caring attitude. toward him. I appreciate it from the bottom of my heart. He really expressed how good it felt to be able to talk to you! Sincerely and may God bless you.
★★★★★
I really appreciate your prompt and highly effective assistance on this matter. After six different OUI attorneys told me that there was no way to recall the warrant and dismiss the charges against me without me returning to Mass from California, you managed to accomplish what they said was impossible. Thanks again!
★★★★★
It took some 30 years,almost the loss of a job,fid card ,arrested ,etc,etc.i tried several lawyers,and got the same disappointing answer ;sorry ,nothing we can do;.One little phone call and back and forth on the iPad,and for the first time i felt positive that this issue could be resolved.MR Goldwyn,and Ms Aisa Fitzgerald told me their game plan,and they made it happen.I am a very ,very happy clam.
★★★★★
Rick Floor is who I often to go to and he is amazing! Great customer service, and always exceeds my expectations but the whole office is always pleasant and helpful when I call or walk in!
Review: Altman and Altman LLP