Both Florida and Federal officials investigate insurance fraud schemes.
The Department of Justice's Criminal Division may bring tax or
health care fraud charges in coordination with another federal agency such as the Medicare-Strike
Task Force or Criminal Investigation unit of the IRS.
At the state level, the Florida Department of Financial Services handles
suspected fraud referrals. Over the last year, for instance, there have
been an increasing number of PIP (Personal Injury Protection) fraud cases
brought by the state agency.
Sentence handed down in recent Miami health care fraud scheme
Federal statute makes it a crime to knowingly or willfully create a scheme
to "defraud a health care benefit program." A fine and prison
sentence of up to 10 years is possible with a conviction. When a scheme
results in serious injury or the death of a patient, the prison sentence
could increase to 20 years or life.
A recent federal prosecution detailed a scheme that ultimately involved
15 people who worked for a health care organization. Prosecutors alleged
that the community mental health center stole money from Medicare and Medicaid.
At trial, the prosecution introduced evidence that a medical record supervisor
altered documents to support false billing claims. One of the allegations
was that billed therapy sessions involved patients watching movies or
simply taking part in games or barbeques. It was also alleged that the
supervisor was aware of illegal payments to assisted living facilities
for patient referral information used to submit claims.
Following a federal trial, a jury found the woman guilty of conspiracy
to commit health care fraud. The former supervisor of medical records
at the organization was sentenced to 10 years in prison, an additional
three years of supervised release and must pay a large amount of restitution
for her part.
Necessity of legal representation as fraud prosecutions increase
The number of these health care fraud prosecutions has increased since
2007 when Health and Human Services formed a Medicare Fraud Strike Force.
Approximately, 1,500 prosecutions have resulted.
Fraud charges generally require that the violation was willful. In the health care context,
as in all criminal cases, the defense depends upon the facts of the case
and the applicable law. In the case described above, one defense might
be that an individual was unaware of fraudulent billing practices and
another might be that the billing practices were erroneous, but not fraudulent.
Other possible defenses may relate to the admissibility of evidence or
credibility of testimony.
Any allegation of health care fraud is serious. If convicted, penalties
can include a prison sentence, fines and restitution. Detailed reviews
of paperwork and charges against multiple people in an organization are
common in these types of cases. The complexities of these cases require
a skilled criminal defense attorney to defend you against such charges.