Healthcare Fraud: Medicaid & Medicare

Many cases involving healthcare fraud involve either Medicare or Medicaid, but other criminal investigations also involve private insurance companies or research grants. Medicare Fraud and Medicaid Fraud investigations may result in charges filed in the federal courts. However, some Medicaid fraud investigations are processed through the Oklahoma Attorney General’s Office or the Office of the District Attorney for a particular county. When federal investigations occur, they are generally handled by the FBI or the Office of Inspector General for one of the affected federal agencies, but other agencies such as the FDA or some branches of the military investigative services may also be involved.

Some crimes may include:

  • Medicare Fraud and Abuse
  • Medicaid Fraud and Abuse
  • Billing for services not rendered
  • Upcoding — billing for a higher reimbursable service
  • Performing unnecessary services
  • Kickbacks
  • Unbundling of tests and services to generate higher fees
  • Durable medical equipment fraud
  • Pharmaceutical drug diversion
  • Outpatient surgery fraud
  • Internet pharmacy sales

The Oklahoma Attorney General and the U.S. Attorney’s Offices are both currently investigating many allegations of Medicaid fraud. These allegations generally involve claims that the services were not performed at all, that the services were unnecessary or that the services were provided but by someone not legally authorized to perform the service. There is currently an emphasis on two types of fraudulent Medicaid services: (1) pain management, particularly prescriptions for opiates (Oxycontin, Lortab, Hydrocodone, etc); and (2) counseling services primarily home-based.

The “opioid epidemic” or the “Oklahoma opioid crisis” has raised red flags for Medicaid investigators looking at doctors issuing a substantial amount of opiate prescriptions or renewing opioid prescriptions. The investigators are watching the PMP (prescription monitoring program) to determine which physicians are filling quantities of opioids and watching to see how many refills are being issued to each patient. If a physician is not conducting an actual physical and history or not doing blood work on a routine basis when prescribing opiates, a criminal investigation is very possible.

The Oklahoma Attorney General Medicaid Fraud Unit is also conducting investigations into Medicaid billing fraud related to psychologists and counselors (LPC’s, LMFT’s, Behavioral Specialists, and Rehabilitative Specialists). Many of these investigations focus on home-based services where it is alleged the counseling professional either is not providing the services at all or alternatively is “up-coding” or “up-charging” for the actual service provided. Another focus for the Medicaid agents is to look for fraudulent billing practices because of violations of the Medicaid billing rules and regulations (such as billing for travel, billing on the wrong day instead of the date of services, etc).

Healthcare fraud schemes may be charged as wire or mail frauds in general and are usually combined with conspiracy charges, criminal tax charges and/or money laundering. Others are charged with Medicaid Fraud, violation of the Oklahoma Computer Crimes Act and grand larceny. The punishment range for mail and wire fraud is generally up to 20 years. For other crimes, the range of punishment varies. However all healthcare fraud allegations are serious felony matters if charged.

There are many defenses to allegations of healthcare fraud. Many times, there is a medical reason for the procedures that is in dispute. The treating physician has a better understanding of what is required for treatment for a particular patient — not some investigator or insurance company. Other times, the healthcare regulations are ambiguous. In other cases, the procedures were in fact performed as claimed. Once we review the facts, we will find a defense.

Experienced Health Care Fraud Lawyers

Call the Wyatt Law Office at 405.234.5500 for your Oklahoma Healthcare Fraud Lawyers and Attorneys.  Your future is our business.

Noteworthy Cases

Healthcare Fraud Conviction Reversed, Case Dismissed. In the early 1990s, Bob Wyatt was co-counsel to two obstetric physicians and surgeons charged with multiple counts of “healthcare fraud” for alleged violation of CHAMPUS regulations as it related to over 100 patients of the surgery center. This four-year federal investigation in parallel civil and criminal proceedings concluded in a guilty verdict on all but one charge; however, Wyatt convinced the federal appeals court to reverse the conviction with orders to dismiss the charges for lack of merit. Bob Wyatt briefed and argued the appeal to the U.S. Court of Appeals for the Tenth Circuit. (See “Published.”)United States v. Avery, 34 F.3d 1517 (10th Cir. 1994).*