Protecting Your Rights And Your Future

Lexington Health Care Fraud Lawyer

Have you been notified of an insurance audit or accused of health care fraud? At Oakley & Oakley, LLC, I can help you defend your rights and future. Contact me, attorney Jay Oakley, today at to schedule a free case review. If you are a health care provider, a conviction for health care fraud can prevent you from using your license permanently. This is a serious offense, and a conviction can result in severe penalties, including lengthy imprisonment and substantial fines. I pride myself on finding solutions to my clients’ problems. When I am representing health care providers, I do everything possible to keep their licenses intact and untouched. I offer a free consultation to discuss your case and explain your legal rights and options.

How I Can Help If You Are Facing Health Care Fraud Charges In Lexington, Kentucky

Health care fraud defense is highly specific, and many criminal defense lawyers do not regularly work in this area. Because they don’t understand this area of law, they may encourage clients to accept a plea when, in fact, they are not guilty. Choosing a lawyer to represent you who understands the legal charges is not only important, but it is also necessary.  When you hire me, a federal crimes attorney at Oakley & Oakley, LLC, I understand that everything is at stake and will take your legal matter seriously. I am attorney Jay Oakley, and I will explore every available avenue to get your case dismissed, have evidence excluded or suppressed, or negotiate reduced charges. I will also prepare your case for trial so that I can argue your case in front of a judge or jury, if necessary. I represent all types of licensed medical professionals, including:

  • Doctors
  • Chiropractors
  • Dentists
  • Mental health professionals/therapists
  • Nurses and nurse practitioners
  • Pain management specialists
  • Pharmacists
  • Other licensed health care professionals.

Federal investigations are complex matters, especially when multiple agencies are involved. When you hire me, I will work with experts – including former FBI agents, private investigators, medical billing and coding experts, medical experts and compliance officers – to establish proof that either medical services were necessary or that fraud was not committed. I represent clients across Lexington and throughout Fayette County – call me to get started with a free health care fraud defense evaluation today.

What Is Health Care Fraud?

According to the National Conference of State Legislatures, health care fraud costs insurers between $70 billion and $234 billion every year. Getting accurate figures is impossible, because not all fraud is discovered and not all claims turn out to be fraudulent. However, any allegations of health care fraud are taken very seriously. Agencies can take many different types of actions against health care practices, all with significant penalties and consequences, even being required to pay the government’s legal fees. In the United States, there are four laws most commonly used to charge people with health care fraud. These are:

  1. Criminal Health Care Fraud Statute: This comprises two statutes (18 U.S.C. §1347 and §1349), health care fraud and conspiracy to commit health care fraud, that make it illegal for medical care providers to defraud or knowingly make false claims against a health care benefit program.
  2. The False Claims Act: This is an act designed to help taxpayers recover money that has been stolen from the federal government, and it is often used to guard against fraudulent Medicare claims. In 2015 alone, the Justice Department recovered $3.5 billion in settlements and judgments under the False Claims Act, including $1.9 billion from companies and individuals in the health care industry (federal losses alone).
  3. The Stark Law: The Stark Law (Stark Amendment to Omnibus Budget Reconciliation Act of 1989) is a law that applies to physician referrals to entities in which they have financial interests.
  4. Anti-Kickback Statutes: These statutes – 42 U.S.C. § 1320a-7b(b) – make it illegal for physicians and other health care providers to swap goods or services for business opportunities under insurance providers. This type of “cash for patients” fraud can occur even if patients need service and the care they receive is of good quality.

It is possible that you could be charged with other white collar crime charges as well as health care fraud charges brought later. If you work closely with other health care providers and they have been charged with any health care fraud, you may benefit from speaking to legal counsel.

How Do I Know If I’m Being Investigated For Health Care Fraud?

Health care fraud investigations can take different shapes. Sometimes, an indictment may be unsealed simultaneously with the execution of a search warrant, and you will have no notice. If you receive any of the following, you need counsel immediately:

  • Increased audits and record requests by Medicare, Medicaid and commercial insurance companies
  • Suspension from Medicare based on allegations of fraud (credible or suspected)
  • Civil investigative demand (CID)
  • Search warrant
  • Grand jury target letter
  • Grand jury subject letter
  • Grand jury subpoena
  • Grand jury witness letter (witnesses often turn into subjects without legal counsel)

The FBI is the primary agency for investigating and exposing health care fraud. The agency may form “investigative partnerships” with other agencies, including:

  • U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG)
  • Food and Drug Administration (FDA)
  • Drug Enforcement Administration (DEA)
  • Defense Criminal Investigative Service (DCIS)
  • Office of Personnel Management-Office of Inspector General (OPM-OIG)
  • Internal Revenue Service-Criminal Investigation (IRS-CI).
  • Local law enforcement agencies.

If you receive notice of investigation in a civil action or administrative action, you should also prepare for a criminal investigation. The sooner you have representation, the sooner they can begin taking steps to protect you. If your office is raided, your phone and computer may be taken away, and you may feel that you have no choice but to talk to investigators. Always remain calm, and remember: Agents cannot force people to speak.

What Does The Prosecution Have To Prove To Get A Health Care Fraud Conviction?

If you are charged with health care fraud, the prosecution will focus on proving three things:

1. Fraudulent Intent

To be successful in a conviction, federal prosecutors must establish that you intended to “knowingly and willfully execute” a scheme or artifice to defraud a health care benefit program.

2. Fraudulent Activity Or Attempts

If the prosecutor cannot prove that fraud was actually committed, they may instead try to prove that fraud was attempted. The U.S. health care fraud statute does not distinguish between actually committing fraud and attempting to commit it.

3. Target Of Fraud Was A Health Care Benefit Program

The target of a scheme must be a government or private health care benefit or insurance company, organization, etc. Health care fraud can refer to a wide variety of conduct designed to obtain a financial benefit to the detriment of a health insurance or government entity. In some cases, patients are harmed; in other cases, they are not. Common health care fraud schemes include:

  • Billing for medical services that were not performed. The term “ghost patients” may be used to refer to patients who do not exist or who never received the billed service.
  • Falsifying a diagnosis to justify diagnostic tests, procedures or surgeries that are medically unnecessary – in other words, performing and submitting claims for services when there is a lack of medical necessity
  • Unbundling, a form of billing multistep procedures separately instead of as one single procedure
  • Billing for more costly service than is actually performed
  • Waiving co-pays or deductibles and overbilling the insurance carrier
  • Misrepresenting procedures performed to cover non-covered surgeries

Medicare, Medicaid, Tricare and health insurance companies like UnitedHealthcare, Anthem, Aetna, Cigna Health and Humana all work with state and federal law enforcement to prevent, detect and prosecute cases of health care fraud. If you know that you are being investigated for health care or Medicare fraud, do not wait until you are charged.

Telemedicine And Telehealth Fraud

The COVID-19 pandemic has changed health care. Following the coronavirus pandemic, telemedicine is on the rise. Doctors are billing the same rates to talk to patients on Zoom and Skype, and patients can receive prescriptions from doctors without having to leave their homes. The use of phone or video appointments protects patients and doctors and is convenient, but it has also created new priorities for abuse and fraud. If you are accused of health care fraud related to care during the COVID-19 pandemic, do not delay in contacting me.

What Are The Penalties For Health Care Fraud Convictions In Kentucky?

Penalties for health care fraud can be criminal, civil and administrative. Strategies for health care fraud defenses should never be based on potential jail time alone. Having a lawyer who understands the extent of what is at stake is critical to obtaining the best outcome. Potential penalties for health care fraud include:

  • Up to 10 years in federal prison
  • Fines of up to $250,000 per offense
  • Forfeiture of assets related to the alleged offense
  • Loss of board certification status
  • Loss of employment
  • Loss of professional license (medical license, nursing license, pharmacy license, etc.)
  • Mandatory exclusion from billing Medicare and Medicaid for between five years to life
  • Prepayment checks for future claims
  • Restitution to victims

People charged with health care fraud often face multiple criminal charges, which can exponentially increase penalties. Along with health care fraud, they may be charged with:

  • 18 U.S.C. 1343 – Wire fraud
  • 18 U.S.C. 1344 – Bank fraud
  • 18 U.S.C. 2320 – Counterfeiting
  • 18 U.S.C. 1961 – Racketeering
  • 18 U.S.C. 1956 – Money laundering
  • 21 U.S.C. 841(a) – Drug trafficking
  • 42 U.S.C. 1320a-7b – Anti-Kickback Statute
  • 18 U.S.C. 371 – Conspiracy

Of course, every situation is unique and different. You should not assume that because someone wasn’t charged, you won’t be charged, either. If you know that you are under investigation for any type of white collar crime, contact me at Oakley & Oakley, LLC.

What Defenses Can Be Used To Fight Health Care Fraud Charges In Lexington?

Health care fraud is a type of white collar crime. There are a number of defenses available to someone charged with health care fraud. These include:

  • Mistake: Intent is an element of a health care fraud crime. If the claims were submitted mistakenly or erroneously, the act cannot be considered fraud. Innocent errors are often referred to as a “good faith defense.” This defense may not work in every situation.
  • Someone else committed the fraud: Billing tasks are often divided up, and it can be unclear who was working on legitimate tasks and who was acting fraudulently. For example, if a second employee submits information to insurance companies, they may be just completing assigned tasks without knowledge of the allegedly fraudulent activity.
  • Constitutional violations: Government agencies and the police have to abide by certain rules when investigating allegations of health care fraud. If your rights have been violated – perhaps through an unlawful arrest or illegal search and seizure – it’s important to raise those issues with the court. It could lead to getting evidence suppressed or having a judge toss the charges against you entirely.

If you are investigated or charged with health care fraud, you are up against prosecutors with endless resources and a complex system. This can be an incredibly stressful and uncertain time. Do not risk your future by hiring an unqualified lawyer to represent you.

Get a Free Consultation With A Lexington Health Care Fraud Lawyer At Oakley & Oakley, LLC

At Oakley & Oakley, LLC, I have more than 15 years of experience handling white collar crimes like health care fraud, so I understand how much is at stake. Call my law offices today to discuss your case with me. Your initial consultation is free.