Health Care Fraud

The health care industry is among the most highly regulated economic sectors in the United States, exposing health care professionals of all kinds to accusations of fraud. Doctors, residents, nurses, hospitals, pharmacies, drug companies, and others are constantly subject to investigation and prosecution for a wide variety of alleged misconduct. Both state and federal prosecutors bring health care fraud cases, and the courts typically treat these prosecutions very seriously. Despite the spotlight placed on health care fraud, however, these cases can be defeated. Strong and persuasive defenses to health care fraud accusations are available with the right legal representation. If you are facing allegations of health care fraud, you need an experienced and highly-qualified attorney to defend you and your reputation.

Boston health care fraud attorney David J. Grimaldi provides outstanding representation to health care professionals accused of criminal and civil misconduct. He represents clients in all aspects of health care fraud matters, including investigations by law enforcement, grand jury proceedings, witness representation, pretrial litigation, and trials. He also represents health care providers accused of professional misconduct before the Board of Registration in Medicine (BORIM). Attorney Grimaldi knows how seriously his clients value their freedom and their career, and he unwaveringly pursues the absolute best possible result for his clients.

While allegations of health care fraud take many forms, the heart of most cases concern purportedly false representations intended to secure something of value, usually money. In many instances, the target of alleged schemes to defraud are government health care programs, including Medicare and Medicaid. Examples of health care fraud include:

• Kickbacks and Bribery: In some industries, it is common to compensate others who refer business to you. In the context of federal health care programs, however, paying for referrals is a crime. The federal Anti-Kickback Statute (“AKS”), 42 U.S.C. § 1320a-7b(b), targets hidden financial arrangements between health care providers by prohibiting the exchange, or offer to exchange, anything of value in order to induce or reward the referral of business reimbursable by federal health care programs.
• Improper Financial Interests and Self-Referrals: Multiple statutes prohibit health care providers from having a direct financial interest in particular services provided to their clients. For instance, the federal Stark Law, 42 U.S.C. § 1395nn and § 1396b, prohibits physicians from referring patients for certain health services paid for by Medicare to any entity in which they have a “financial relationship.”
• Billing for Services Never Rendered: Submitting claims for medical services, treatments, tests, supplies, or pharmaceuticals that were never provided are prosecuted in both state and federal court. The Attorney General of Massachusetts, for example, maintains a Medical Fraud Division that investigates and prosecutes health care providers who, they claim, defrauded the state Medicaid program known as MassHealth. In federal court, similar cases are often prosecuted under the False Claims Act.
• Upcoding: Submitting claims for services more expensive than those that were actually performed, sometimes called “upcoding” in reference to the numerical codes used in billing procedures, is often charged as a violation of the federal False Claims Act and other statutes.
• Bundling and Unbundling: Government health care programs such as Medicare and Medicaid have special reimbursement rates for procedures that are often performed together, otherwise known as a “bundled” rate. Health care providers who “unbundle” those procedures by billing for them separately would receive a greater reimbursement rate. In some circumstances, the government charges health care professionals for “unbundling” claims with an intent to defraud.
• Billing an uninsured medical service or procedure as a covered service or procedure. Efforts by health care practitioners to secure payment for uninsured medical services by submitting claim forms for insured services is a commonly prosecuted offense in state and federal court.
• Lack of Medical Necessity: Performing medically unnecessary services in order to inflate claims submitted for payment is a commonly prosecuted criminal offense. Prescribing medically unnecessary drugs is another frequently charged crime.
• Forging or Falsifying Documents: Forging or fraudulently altering documents in the medical field can be a criminal offense. Sometimes, health care providers are accused of inflating the number of “office visits” made by a patient to receive services, since each visit is generally considered a separate billable service. Other times, providers are accused of falsifying medical records in order to justify medically unnecessary services or procedures. Such forgery or falsifying of medical documents is often charged as a form of health care fraud.

Boston health care fraud attorney David J. Grimaldi is an expert in challenging the government’s fraud accusations against his professional clients. While there are many defenses to health care fraud cases, the intent of the client is often among the most important questions in such cases. Attorney Grimaldi has successfully contested the prosecution’s claims about his clients’ state of mind in many cases, and he always finds the most effective method to advocate for his clients’ innocence.

If you are charged with health care fraud, you need a successful and experienced attorney to provide the strongest possible defense. Contact Attorney David J. Grimaldi at 617-661-1529 or online today.