Ounces make pounds. Healthcare fraud has the government’s attention because a wide range of deceptive practices and behaviors has led to about $60 billion annually. Although we will provide you with everyday examples of healthcare fraud, it is important to note that this is not a crime solely connected to providers. Using someone else’s insurance card or information is an example of fraud, as is waiving a member’s co-pay. This is a deceptive practice where medical providers waive the copay to encourage patients to return because nothing is coming out of their pocket. Why would they do this? Because they then submit a falsified claim to recoup that co-pay. The insurance company is tricked into paying it on the patient’s behalf. 

Though these two previous examples are fraudulent, they may not carry the same weight in terms of punishment. Our purpose today is to explain healthcare fraud and how it pertains to the federal sentencing guidelines. 

Looking at Healthcare Fraud

We have written previously about federal sentencing guidelines and how the specifics of your crime allow the court to add (or subtract) points before determining the length of your sentence. Healthcare fraud cases also use these sentencing guidelines. Before we elaborate on how that works, we must identify the types of crimes we refer to when discussing healthcare fraud. 

Healthcare is a trillion-dollar industry. Due to the sheer volume of money being exchanged between providers (doctors and healthcare professionals) and patients, insurance companies rely heavily on detailed and accurate documentation of services. This could boil down to adding a code to a claim form for services that were never provided, yet the provider is asking to be compensated by the insurance company. Other common examples include

  • Coding a service that the insurance provider doesn’t cover to a service that is, despite the patient never receiving that service
  • Waiving deductibles, as we mentioned above
  • Providers who deliberately add unnecessary tests to the patients because they want to add more to the patient’s claim 
  • Providers who receive kickbacks or money in exchange for referrals or prescriptions 
  • Patients who provide false information to receive service 
  • Patients who use their insurance to gain (and then sell) prescription medications

How They Apply to Federal Sentencing Guidelines 

Though this is a complicated arena, the simplest way to explain how these fraud cases are connected to federal sentencing guidelines is by looking at the loss amount. Your sentence is directly related to how much was taken—however, we need to discuss that further. Consider the provider who has been caught padding claims with services that were never provided. For example, imagine that they received $2 million through fraudulent claims. Another million dollars in claims were yet to be processed when they were caught. Are they on the hook for two or three million dollars?

Both, but in different ways. If you attempted to defraud the government or an insurance provider for $3 million, that is the amount that gets fed into the federal sentencing guidelines. If you have to pay restitution, you will only be responsible for repaying the money you received—which, in this case, is $2 million. In future blogs, we will look closely at restitution and how it applies to specific situations. 

Meet with a Health Care Fraud Attorney Sabrina Puglisi is not only Puglisi Caramés’s founder, but she holds the distinction of being a Florida Board Certified Criminal Trial attorney. Due to the amount of money involved, the U.S. The Attorney’s Office and judges take this matter seriously. Because of how common lengthy jail sentences are issued, you must speak with an attorney who understands these cases and how to defend you. Contact us today to schedule your free consultation.