The Department of Justice (DOJ) recently announced another massive national health care fraud takedown, with Florida once again being a significant focus of the enforcement action. For practice managers and healthcare business owners across the state, these headlines are more than just news—they are a stark reminder of the complex web of regulations that govern the industry and the severe consequences of non-compliance. These government actions often result in severe penalties for those accused of committing fraud.
These enforcement actions, often involving hundreds of defendants and billions in alleged fraud, are not just targeting hardened criminals. They frequently ensnare well-meaning physicians and practice managers who have made critical errors in their healthcare practice.
Understanding the anatomy of these takedowns is the first step toward protecting your practice from becoming a statistic. Our experienced attorneys can help.
At Ace Your Case, our Florida healthcare fraud defense attorneys believe the best defense is a proactive offense. By analyzing these cases, we can help you build a robust compliance program that shields your business from costly investigations into federal healthcare fraud.
Understanding the Federal Crackdown: The Medicare Fraud Strike Force
A key player in these takedowns is the Health Care Fraud Strike Force, a partnership between the DOJ and the Department of Health and Human Services (HHS). The Miami Strike Force is one of the most active in the country, using advanced data analytics to identify billing anomalies and target healthcare providers for federal investigations. When the Strike Force is involved, it signals that federal prosecutors are taking a health care fraud case seriously. Their focus is often on uncovering widespread Medicare fraud.
What is Considered Health Care Fraud in Florida?
Health care fraud is an intentional act of deception by an individual or entity that results in an unauthorized payment from a health care benefit program. In Florida, this can involve private insurers as well as government programs like Medicare and Medicaid. This type of medical fraud is a primary focus for the federal government. Federal and state agencies, including the FBI, the HHS Office of Inspector General (HHS-OIG), and Florida’s Medicaid Fraud Control Unit (MFCU), are more aggressive than ever in prosecuting fraudulent activity, including Medicaid fraud.
Who is Targeted in Healthcare Fraud Investigations?
While news reports often focus on executives, the reality is that a wide range of healthcare professionals can be caught in the government’s net. From individual physicians to lab owners and hospital administrators, anyone involved in the chain of billing federal health care programs is a potential target. An investigation scrutinizes every aspect of a professional’s operations and decisions, placing their professional conduct under a microscope. Our attorneys have defended a wide range of providers.
Common Schemes Prosecuted as Healthcare Fraud in Florida
While the schemes can be complex, most healthcare fraud cases center on a few key areas of misconduct:
- Fraudulent Billing: This is the most common type of alleged healthcare fraud and can include “phantom billing” (billing for services never rendered), billing for medically unnecessary services, or “upcoding” to a higher reimbursement level. These are all considered false claims.
- Illegal Kickbacks: The Anti-Kickback Statute (AKS) is a federal criminal law that prohibits knowingly and willfully offering or receiving anything of value to induce referrals for items or services paid for by federal healthcare programs. The federal government aggressively prosecutes these financial arrangements as a form of healthcare fraud.
- Physician Self-Referral Law (Stark Law) Violations: This civil statute, often called the Physician Self-Referral Law (Stark Law), prohibits physicians from referring Medicare or Medicaid patients for designated health services to entities with which they have a financial relationship. Stark Law violations are a frequent source of liability, and proving that an arrangement fits within a “safe harbor” is a key component of a successful fraud defense.
- Durable Medical Equipment (DME) Fraud: This often involves complex schemes to submit false claims for medical equipment that was not medically necessary, was never provided, or was part of a larger kickback scheme, leading to accusations of Medicare fraud.
- Prescription Drug Fraud: Illegally prescribing or diverting controlled substances, or billing for medications that were not dispensed, is another area where providers face allegations of submitting false claims.
The False Claims Act: The Government’s Most Powerful Tool
One of the federal government’s most powerful tools in any health care fraud case is The False Claims Act (FCA). This powerful federal law imposes massive liability on any person who knowingly submits false claims to the government. The submission of thousands of false claims can lead to financial ruin for a healthcare practice.
The False Claims Act is the primary statute used to combat healthcare fraud. Defending against allegations under the False Claims Act requires specialized legal knowledge. The government uses the False Claims Act to recover billions of dollars lost to Medicare fraud and other schemes involving false claims.
A key feature of the False Claims Act is its “qui tam” provision, which allows private citizens (whistleblowers) to file lawsuits on behalf of the government for false claims. If the lawsuit is successful, the whistleblower can share in a percentage of the recovered funds, creating a powerful incentive for employees to report suspected healthcare fraud.
Many healthcare fraud investigations and allegations of false claims begin with a disgruntled employee filing a whistleblower lawsuit under the False Claims Act. Defending against these claims requires a sophisticated healthcare fraud defense strategy from experienced attorneys. The complexities of the False Claims Act demand a dedicated legal team. The government’s reliance on the False Claims Act to fight fraud, including Medicare fraud, cannot be overstated. Our attorneys are experts in defending against False Claims Act allegations and the associated false claims.
The Investigation Process: What to Expect When You’re Accused
A healthcare fraud investigation is a daunting experience. It often begins with a Civil Investigative Demand (CID), a subpoena, or an unannounced visit from federal agents. This is a critical moment. Anything you say can be used against you, and making false statements can lead to separate criminal charges.
Responding to a Medicare Audit
Often, a full-blown fraud investigation begins with something more routine: a Medicare audit. These audits are conducted by various contractors for the federal government. While they may seem like simple reviews of your billing, a Medicare audit can quickly escalate into a larger investigation if auditors uncover patterns of non-compliance that suggest Medicare fraud.
Responding appropriately from the very beginning is critical to protecting your practice. An experienced healthcare fraud defense attorney can manage the audit process, challenge incorrect findings, and prevent the situation from spiraling into a more serious allegation of healthcare fraud based on false claims.
The Role of the FBI Investigation
In many cases, an FBI investigation will be a central part of the government’s effort. Agents may interview employees, seize documents, and execute search warrants. Because healthcare fraud cases often involve complex financial transactions, prosecutors may also add related charges like wire fraud if electronic communications were used in the commission of the alleged crime.
It is crucial to remember that the government must prove you had the intent of committing fraud; accidental billing errors are not the same as a criminal scheme involving false claims.
It is essential to secure legal representation from a qualified healthcare fraud defense attorney immediately. While most criminal defense attorneys are skilled litigators, experienced defense lawyers specializing in healthcare fraud understand the specific nuances needed to build an effective healthcare fraud defense against the government’s case. Our team of defense lawyers and attorneys is prepared to handle your case.
Severe Penalties: The Consequences of a Healthcare Fraud Conviction
The penalties for healthcare fraud are severe and can be practice-ending. This is a serious crime with life-altering consequences.
- Crippling Fines and Civil Penalties: Under the False Claims Act, penalties for submitting false claims can include treble damages (three times the amount of the alleged fraud) plus per-claim fines.
- Exclusion from Federal Programs: A conviction for Medicare fraud can lead to being excluded from participating in Medicare and Medicaid.
- Criminal Charges and Prison Time: Executives and physicians face lengthy prison sentences for their involvement in fraud schemes.
- Loss of Professional Licenses: A fraud conviction will almost certainly trigger an investigation by the Florida Board of Medicine or other licensing boards.
How an Experienced Attorney Builds a Healthcare Fraud Defense Strategy
A strong fraud defense strategy begins the moment you learn of an investigation. Your healthcare fraud defense attorney will immediately engage with federal prosecutors to understand the scope of the alleged fraud and begin building your defense.
A successful defense may involve demonstrating that there was no intent to defraud the government with false claims, or that the services provided were a medical necessity. Top defense lawyers will also work to present evidence showing that financial arrangements fell within a legal safe harbor for Stark Law violations.
In some cases, negotiating a plea agreement or settlement may be the best course of action for a health care fraud case. Our attorneys have a proven track record.
If you are facing an investigation, do not wait. Contact us online or call (954) 820-4453 for a confidential consultation with our legal team today.
Meet Our Lead Health Care Defense Attorney
Aaron Draizin
Aaron Draizin is an aggressive and methodical civil litigation attorney with extensive experience representing medical providers against insurance companies. His deep knowledge of insurance defense tactics, gained as a Shareholder at a prestigious statewide insurance defense firm, gives our clients a decisive edge. Aaron now uses his insider knowledge to fight for the rights of healthcare professionals, ensuring you don’t leave any money on the table.
He has been awarded an AV Preeminent peer review rating from Martindale-Hubbell and was named a Florida Super Lawyers Rising Star for five consecutive years.
Proactive Compliance: Your Best Defense Against Fraud Allegations
Healthcare compliance law is the body of rules and regulations that govern the healthcare industry. The key takeaway for any practice manager in Florida is that waiting for criminal investigations is too late. A proactive compliance program, developed with experienced health care compliance lawyers, is the most effective way to mitigate risk and forms the basis of a good-faith fraud defense. A compliance lawyer, one of many attorneys at our firm, can help.
A robust compliance plan should include:
- Regular Risk Assessments: Identifying vulnerabilities in your billing practices that could lead to false claims.
- Written Policies and Procedures: Creating a clear compliance manual for your entire team.
- Ongoing Training: Educating your staff on the complexities of state and federal law.
- Independent Audits: Regularly conducting external audits to review your billing and documentation for accuracy.
Beyond Professional Defense: Comprehensive Legal Support
We understand that legal challenges for healthcare professionals are not confined to regulatory matters. A personal crisis can impact your professional life and financial stability just as severely.
- A serious personal injury from an accident can affect your ability to work. Our firm is also a leader in fighting for the rights of the injured to secure the compensation they deserve.
- As a busy professional, a car accident can be devastating. We handle all aspects of car accident claims, allowing you to focus on your recovery and your practice.
- In the tragic event of a wrongful death, our compassionate attorneys provide steadfast legal support to families during their most difficult times.
Florida Healthcare Fraud FAQs
What are examples of illegal kickbacks?
Examples of illegal kickbacks include a medical device company paying a physician for every device they implant or a hospital paying a physician a sham “medical director” salary in exchange for referrals. These are heavily scrutinized by the federal government.
What is acceptable under the Anti-Kickback Statute?
The AKS has several statutory “safe harbors” that protect certain payment arrangements. These are highly specific, and any arrangement must be carefully structured by legal counsel to ensure it fits squarely within a safe harbor to avoid allegations of healthcare fraud.
What does a health care compliance lawyer do?
A compliance lawyer provides proactive legal counsel to help healthcare businesses avoid violations. Our attorneys draft compliance policies, conduct internal audits, and train staff on relevant laws like HIPAA and the Stark Law.
Contact a Florida Healthcare Fraud Defense Attorney Today
The federal government’s focus on healthcare fraud, particularly Medicare fraud, in Florida is not going away. If you are a practice manager or healthcare business owner, taking proactive steps is essential. A healthcare lawyer is your most important ally.
The legal team at Ace Your Case has extensive experience in guiding medical providers through the complexities of healthcare regulations. Our attorneys can help you build a compliance program that protects your business and provide a vigorous healthcare fraud defense if you are facing an investigation related to the False Claims Act or other federal law.
Don’t let your practice become the subject of the next DOJ press release for submitting false claims. Contact us today to schedule a confidential consultation and learn how our Florida health care attorneys can help you achieve peace of mind.
