Healthcare Fraud Lawyer in Miami

The False Claims Act (FCA)  

The False Claims Act is among the most powerful tools federal prosecutors use in healthcare fraud cases. This law targets individuals or organizations knowingly submitting false or fraudulent claims to government programs, including Medicare and Medicaid.

Key Provisions:

• Prohibits knowingly presenting false claims for payment or approval
• Covers making or using false records to secure government payments
• Includes liability for conspiring to commit any violation of the FCA

Penalties:

• Treble damages (three times the amount of the government’s loss)
• Civil penalties ranging from $13,508 to $27,018 per false claim (adjusted for inflation)
• Criminal charges in cases involving egregious misconduct

Qui Tam (Whistleblower) Provision:

• Allows private individuals (whistleblowers) to file lawsuits on behalf of the government
• Whistleblowers may receive a portion of the recovered funds, incentivizing reports of fraud

The Anti-Kickback Statute (AKS)  

The Anti-Kickback Statute criminalizes offering, paying, soliciting, or receiving any form of remuneration in exchange for referrals or business involving federal healthcare programs.

Key Provisions:

• Prohibits kickbacks, bribes, or rebates to induce referrals for services covered by Medicare,
• Medicaid, or other federal programs
• Applies to both direct and indirect forms of payment or benefit

Penalties:

• Criminal penalties, including up to 10 years in prison per violation
• Fines of up to $100,000 per violation
• Exclusion from participation in Medicare and Medicaid programs

Safe Harbors:

• Certain arrangements (e.g., discounts or value-based incentives) may qualify for safe harbor
• protections if they meet specific regulatory requirements.

The Stark Law (Physician Self-Referral Law)  

The Stark Law prohibits physicians from referring patients for certain designated health services (DHS) to entities with which the physician or an immediate family member has a financial relationship unless an exception applies.

Key Provisions:

• Applies to services billed to Medicare or Medicaid
• Covers financial relationships such as ownership, investment interests, or compensation arrangements
• Strict liability statute states intent does not need to be proven for a violation

Penalties:

• Denial of payment for DHS provided in violation of the law
• Civil penalties of up to $27,000 per claim
• Additional fines of up to $160,000 for circumvention schemes

Exceptions:

Includes exceptions for certain types of financial relationships, such as employment agreements, in-office ancillary services, or specific rental arrangements.

Additional Federal Statutes

Health Care Fraud Statute (18 U.S.C. § 1347):

• Criminalizes schemes to defraud healthcare programs or obtain money through false representations
• Penalties include up to 10 years in prison or 20 years if bodily harm results from the fraud

The Criminal False Statements Statute (18 U.S.C. § 1001):

• Prohibits making false statements or concealing material facts in dealings with federal agencies
• Used in cases involving false information on Medicare or Medicaid enrollment forms

The Exclusion Statute (42 U.S.C. § 1320a-7):

Authorizes exclusion of individuals or entities from federal healthcare programs for fraud, abuse, or other misconduct.