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Ileana Hernandez Explains How Healthcare Fraud is Prosecuted

Healthcare fraud is massive.

As the cost of healthcare continues to rise, fraud in today’s healthcare system is rampant. Examples of fraud include providers overcharging for services or billing prescriptions that were not provided. The US Department of Health and Human Services (HHS) has recognized this growing problem and has set forth several guidelines to help prevent fraud among healthcare providers and patients.

Ileana Hernandez of Manatt says, “The government is taking a lot of action to investigate suspected sources of healthcare fraud.”

Statistics show that the Department of Justice (DOJ) has doubled its number of convictions for healthcare crimes over the past five years.

According to Hernandez, “Healthcare fraud can be prosecuted as a criminal case or can be handled as a civil case.”

In the criminal prosecution of healthcare fraud, prosecutors will charge individuals and companies involved in defrauding government insurance programs such as Medicare and Medicaid with one or more offenses: conspiracy, false claims (or submissions), wire fraud, mail fraud, and health care fraud.

In the healthcare industry, all eyes are on those who have been charged with fraud due to investigations conducted by either a federal or state agency. Hernandez says, “To discourage others from engaging in similar conduct, the government will often publicize its prosecutions.”

Another tool in the government’s arsenal is the False Claims Act (FCA). The FCA is a federal law that allows individuals to file lawsuits on behalf of the federal government. A person may file an action under this statute if they possess information that can be used in a case against someone who has defrauded the government. Furthermore, because the FCA provides for a bounty to whistleblowers whose actions lead to a successful recovery, it has been used as a tool for the government to encourage individuals who possess knowledge of fraud against the government to come forward with that information.

“The FCA is a primary vehicle that the federal government uses to fight healthcare fraud cases,” says Hernandez. “Over 80 percent of the healthcare fraud cases brought by the government are done so via the FCA.”

When pursuing a civil case, the focus is on allocating monetary damages among those responsible for committing healthcare fraud. For example, the False Claims Act provides that any person or corporation who submits false claims to be paid by Medicare or Medicaid will have to pay three times the amount of damages plus penalties for each false claim. Additionally, there are provisions under the FCA that provide civil fines between $5,500 to $11,000 per claim.

Because healthcare fraud can affect people’s lives and well-being, government officials must crackdown on those who choose to participate in it. “When you are talking about Medicare, people are usually thinking of old people,” says Hernandez. “But, 1 out of every 10 Americans is on Medicare right now. Fraud against the government affects all of us in the US.”

In closing, Hernandez explains, “The US Department of Justice, HHS, and Congress are making a concerted effort to go after healthcare fraud.”