Every day I read the press releases from healthcare fraud prosecutors around the country describing how some cases settle for millions of dollars with no criminal charges, while other cases result in lengthy prison sentences even though much less money was involved. Two cases that came to my attention today illustrate when and how a healthcare fraud dispute becomes a criminal offense.
The first case involves a former chiropractor who was accused of submitting a little more than $180,000 in false claims. He was sentenced to 44 months in prison and an additional three years of supervised release after pleading guilty to health care fraud. He was also ordered to pay $183,674.14 in restitution.
As far as health care frauds go, this one did not involve a tremendous amount of money. There were several factors, however, that made this a criminal case.
First, the former chiropractor was already serving 60 months in prison on charges of domestic abuse and battery involving strangulation.
Second, the former chiropractor was accused of billing for chiropractic services, back braces, and X-rays that he did not actually provide to patients.
Third, the former chiropractor was accused of inducing patients to agree to an expensive test that they did not want or need by agreeing to reduce or eliminate their co-payment if they agreed to let him perform the test.
Fourth, the former chiropractor was accused of fraudulently billing for services using physician provider numbers without authorization, or on days when the physicians were not working in his clinic.
In contrast, a second case that came to my attention involved an $8 million settlement of false claims that will result in no criminal prosecution at all if the defendant complies with the terms of a deferred prosecution agreement.
An OB/GYN in New York was accused of submitting more than $8 million in false claims to Medicare by billing for services provided by unlicensed and unsupervised staff. Instead of going to prison, however, this physician was able to negotiate a deferred prosecution agreement.
Under the agreement, the physician will pay back the disputed amount and will retain an independent billing monitor to oversee the billing in his practice. If he complies with the terms of the deferred prosecution agreement for a period of two years, the prosecutors agree to drop the criminal charge against him.
Unlike the chiropractor in the first case, the OB/GYN did not have any other criminal problems and was not billing for services that were not provided or that were not medically necessary. By retaining an experienced Medicare fraud criminal defense attorney early in the process, he was able to highlight these facts and others to prosecutors, with a very favorable result.
John Howley, Esq.