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Health Care Fraud

The federal government provides a massive amount of services and benefits to residents of the U.S. – infrastructure, law enforcement, student financial aid, health care coverage, and more. It is virtually impossible to live within the nation and not obtain some benefit from the government. Unfortunately, there are many people out there who wish to take advantage of these benefits, or when the time comes, hide from paying their fair share. These individuals attempt to defraud the government, and when their schemes are successful, they cost the government billions of dollars each year.

However, the federal government has a number of statutes in place that create civil and criminal liability for individuals who attempt to defraud it, including the False Claims Act, the Anti-Kickback Statute, and the Stark Law. The government also has the resources to investigate potential fraudulent schemes and prosecute individuals who have violated these or other laws.

The federal government also relies on private individuals to come forward when they know of fraud. They rely on whistleblowers to put their careers and reputations on the line in order to help the government shut down illegal activity. If you believe you have information regarding fraud and are to come forward, call a San Francisco health care fraud lawyer at Willoughby Brod, LLP today.

Health Care Fraud

The False Claims Act (31 U.S.C. § 3729) protects against all types of fraudulent claims made to the federal government. However, one of the most common industries for fraudulent claims is health care. In fact, it is so common that the Department of Justice (“DOJ”) and other government agencies have formed a Health Care Fraud Unit, which includes the Health Care Fraud Prevention & Enforcement Action Team (“HEAT”) and the Medicare Fraud Strike Force.

Physicians and other health care providers devise a variety of schemes to submit false claims to Medicare, Medicaid, and TRICARE. Medicare is a federal program with the purpose of providing health care to the elderly (anyone over 65 years old) and individuals with disabilities, as defined by federal law. Medicare is broken down into Parts A, B, C, and D. Part A provides for necessary inpatient stays at hospitals, nursing facilities, and hospice. Part B is similar to medical insurance and covers preventative care and physicians’ services. Part C enables private insurers to offer Medicare benefits, and Part D is a prescription drug plan.

Medicaid is a program run jointly by the federal and state governments to provide health care coverage for individuals with low incomes, certain pregnant women, certain children, and individuals on Supplemental Security Income (SSI). Each state runs its own Medicaid program, and some have chosen to offer expanded coverage.

TRICARE is the federal health care program for military service members and their families.

If you are aware of an intentional scheme to defraud any federal or statute health care program, immediately contact a San Francisco health care fraud lawyer for advice on how to proceed.

Anti-Kickback Statute

There are more federal laws than the False Claims Act (“FCA”) that protect the government from fraudulent behavior. The Anti-Kickback Statute, 42 U.S. Code §1320a-7b(b), prohibits individuals from offering, paying, asking for, or receiving anything of value to induce or reward referrals or general federal health care program business. Many illegal kickbacks are payments, some of which are hidden through various false transactions between people or businesses. However, illegal kickbacks can also be gifts, like expensive sporting event tickets or vacations under the cover of professional conferences.

Individuals who are found to have given, offered, received, or solicited illegal kickbacks within the health care industry can face civil fines and criminal penalties. For each violation of this statute, an individual can be sentenced to up to five years in prison.

If you know of bribes being paid between physicians, other health care providers, or medical device providers, contact a health care fraud lawyer in San Francisco today.

Stark Law

Under 42 U.S. Code §1395m, it is illegal for a physician to refer Medicare patients for certain health services to a facility with which the physician or one of his or her immediate family members has a financial relationship, unless a specific exception applies. If a doctor does refer a Medicare patient to a facility with which he or she has a financial relationship, that facility cannot submit a claim to Medicare for the relevant services.

This law is intended to stop physicians from referring patients to businesses if the physician will ultimately profit from the patients going there. The purpose of the law is to ensure that physicians focus on what is best for their patients and not the financial aspects of providing care.

Physicians who violate this statute, either in making illegal referrals or submitting a claim based on a prohibited referral face civil consequences, including high fines.

If you are aware of a physician or facility making or accepting referrals in violation of Stark Law, speak with a health care fraud attorney practicing in San Francisco.

Let a San Francisco Health Care Fraud Attorney Help

You may have information about how someone is billing the government and wonder if it is illegal or not. You may wonder, if it is illegal, what do you do about it? By calling Willoughby Brod, LLP, you can obtain answers to your questions. A lawyer experienced in health care fraud, qui tam and whistleblower lawsuits is the best person to explain your rights and options.

Whatever your options, and whatever you choose, Willoughby Brod, LLP will guide you through the legal process.

It may be that you are in the position to come forward and provide the government with information. Or, you may have the right to file a qui tam lawsuit on behalf of the government yourself.

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