Healthcare Fraud & False Claims Act

Healthcare Fraud & False Claims Act

Healthcare Fraud and False Claims Act Defense Lawyer

Healthcare Fraud & False Claims Act

At Delahunty & Edelman LLP, we help our clients in the healthcare industry to implement the proper policies, procedures, and programs to educate their staff; provide accuracy and accountability; ensure compliance with applicable regulations; and minimize their legal risks.

Our attorneys also represent clients in the healthcare industry who are facing investigations into or charges of healthcare fraud to quickly resolve the dispute in a discreet and cost-effective manner and mitigate criminal and civil liability.

What is Healthcare Fraud?

Healthcare fraud is an umbrella term used to describe a fraudulent attempt to obtain payment or reimbursement of healthcare services or equipment. It can involve federal criminal penalties under 18 U.S.C. §1347 and §1349. Individuals and organizations can also be held civilly liable under legislation like the False Claims Act.

Healthcare fraud may occur in connection with government healthcare programs like Medicaid, Medicare, and Tricare. It can also take place in the form of fraudulent federal workers’ compensation claims.  Additionally, it may involve fraudulent conduct directed towards private healthcare providers, such as Blue Cross or Cigna.

Federal healthcare fraud claims may involve:

  • Medicare and Medicaid regulations
  • The False Claims Act
  • Stark Law (the Physician Self-Referral Law)
  • Criminal Healthcare Fraud Statute
  • Foreign Corrupt Practices Act
  • Unfair Trade Practices
  • State and Federal Anti-Kickback Statutes
  • Civil Monetary Penalties Law

If you are involved in one of the following situations, or if through an internal audit or investigation, whistleblower complaint, government investigation, or any other means you find that someone within your organization has committed one of the following actions, you or your organization may be criminally and civilly liable.

These actions include, but are not limited to:

  • Falsifying documents
  • Billing for services that were not provided
  • Billing for services that were not medically necessary in order to collect payment
  • Paying kickbacks for patient referrals
  • Upcoding
  • Unbundling
  • Unlawfully prescribing and/or dispensing controlled substances
  • Prescribing drug buy-backs
  • Medicaid fraud
  • Medicare fraud

Penalties for Healthcare Fraud

The civil and criminal penalty for healthcare fraud varies depending on the underlying offense and the harm caused by the fraud. If convicted of criminal healthcare fraud, defendants face up to 10 years in prison for each count of healthcare fraud, up to 20 years for each count resulting in serious bodily harm, and a life sentence for an offense resulting in death. If a broader scheme of fraud existed, an individual may face imprisonment and fines for multiple counts of fraud and related offenses.

Furthermore, there are consequences to a healthcare fraud conviction that go beyond jail time and fines. Additional penalties may include loss of staff privileges, Medicare exclusion, loss of DEA registration, and the implementation of corporate integrity agreements.

Healthcare Compliance

At Delahunty & Edelman LLP, we are also able to assist with developing, establishing, and enforcing corporate compliance programs to comply with federal and state healthcare laws including HIPAA, EMTALA, HITECH, Medicare, Medicaid, licensure/certification requirements, Sarbanes-Oxley, and more.   Our background in both prosecuting these cases and defending individuals charged of them gives us sharp insights we use to help our clients.  For example, we recognize that the key to defending any charges of misconduct often involves sorting through large amounts of data and determining the one or two key issues of fact that typically decide criminal charges.

Our team of attorneys are also skilled and experienced at conducting efficient and discreet internal audits and investigations to resolve disputes and minimize liability. As former federal prosecutors, we help our clients handle government investigations and resolve compliance issues before they give rise to litigation or criminal charges.

Understanding the False Claims Act

The False Claims Act is a federal law that punishes individuals, companies, and other organizations that fraudulently bill or withhold money from the United States government. The Act allows private citizens to bring claims of fraud on behalf of the government through qui tam claims, which is shorthand for a Latin phrase meaning “who sues in this matter for the king as well as for himself”, derived from a historical legal mechanism that allowed commoners to bring a claim for economic damages suffered by the King.

In modern claims like these, the False Claims Act provides an incentive to private citizens to bring a claim on behalf of the government for a share of 15% to 30% of the damages awarded.

Examples of actions that may constitute a violation of the False Claims Act include:

  • False claims to Medicare or Medicaid
  • Kickbacks for referrals
  • Billing for services not rendered
  • Fraudulent procurement of government contracts

Penalties for violations of the False Claims Act include up to over $23,000 per false claim made or submitted.

An FCA claim may be accompanied by parallel government investigations and/or criminal charges. It is crucial for individuals and organizations facing such investigations to seek counsel experienced in the securities, insurance, and criminal issues that often accompany these disputes.

Healthcare Fraud and False Claims Act and Defense Attorneys in San Francisco and Throughout California

If you or your organization have been accused of healthcare fraud, or if you have been asked to answer questions in an investigation that may give rise to healthcare fraud charges, it is important that you seek legal advice as soon as possible.

Our team of knowledgeable and experienced attorneys at Delahunty & Edelman LLP defend clients involved in government civil investigations relating to alleged healthcare fraud or False Claim Act violations. We are here to assist in conducting independent internal investigations. We have the knowledge and experience to guide you through these highly sensitive matters.

As former Assistant U.S. Attorneys, Patrick Delahunty and Will Edelman bring the perspective and experience of federal prosecutors who have obtained convictions against multiple defendants for fraud in California including those in the healthcare industry. With experience on both sides of these cases, our team is well positioned to examine evidence in your case and to develop a defense strategy.

Our goal is to resolve these allegations as quickly as possible and fully exonerate our clients or substantially mitigate the charges and penalties against them. 

For more information contact us today at (415) 891-6210 for a confidential consultation of your case.


contact us today