In Operation Brace Yourself, DME and medical brace manufacturers were alleged to have paid “kickbacks” and “bribes” to doctors and nurse practitioners working with telemedicine companies for exchange for Medicare patient referrals for medically unnecessary braces.

In Operation Double Helix, patients nationwide were allegedly lured into providing their DNA for testing in a widespread genetic testing fraud scheme powered by a large telemarketing network. The doctors and nurse practitioners involved were paid to write orders prescribing the testing without any patient interaction or with only a brief telephone conversation.

Healthcare fraud remains a key target of the United States Department of Justice (DOJ). The DOJ uses civil penalties, as well as criminal charges, to punish healthcare fraud. The DOJ views healthcare fraud as a major issue.

CIVIL

  1. False Claims Act (FCA).  The statute prohibits a person from knowingly presenting (or causing to be presented) a false or fraudulent claim for payment to the federal government. It also prohibits knowingly making a false statement material to a false or fraudulent claim. The FCA covers wrongful conduct like “upcoding” and “unbundling,” as well as submitting claims for procedures that were not undertaken at all.
  1. Stark Law. The Stark Law prohibits a physician from referring a Medicare patient for certain designated health services to any entity in which the referring physician has a financial relationship.

CRIMINAL

  1. Anti-Kickback Statute (AKS). The AKS is a criminal statute that prohibits offering or providing anything of value to induce the referral of Medicare or Medicaid business. Please see https://www.justice.gov/opa/pr/federal-indictments-and-law-enforcement-actions-one-largest-health-care-fraud-schemesThis was the beginning of a massive amount of criminal charges nationwide.
  2. Criminal health care fraud statute. Under this statute (18 U.S.C. § 1347), a person can be held liable for a scheme to intentionally (1) defraud any healthcare benefit program or (2) use false statements to obtain funds held by a federal healthcare program. The penalties are steep: up to 10 years in prison and a fine up to $500,000 or twice the amount of the fraud.

The DOJ will continue to investigate these type of cases aggressively. That is why you need to call an experienced lawyer as soon as there appears to be an indication of an investigation.