State Health Care Fraud

i-resourcesInsurance Fraud

Each state has its own health care fraud and abuse prohibitions which are similar to their federal counterparts. Some state laws are limited to fraud and abuse affecting the Medicaid program, but many state fraud and abuse laws apply to all payors.

In Pennsylvania, investigation and prosecution of health care fraud and abuse is generally conducted by the Office of Attorney General, although the District Attorney of each county in the Commonwealth can begin a criminal action.

The Office of Attorney General created a Medicaid Fraud Control Unit whose purpose is to investigate and prosecute fraud committed by medical providers enrolled in the Medicaid program, as well as to investigate patient abuse and neglect in Medicaid funded health care facilities. The Medicaid Fraud Control Unit is comprised of prosecutors, agents and auditors housed in three regional offices across the Commonwealth, and has the authority to file felony and misdemeanor charges against those who defraud the Medicare program or commit patient neglect.

Criminal charges for state health care fraud can be brought for some of the same reasons as those brought for a violation of the federal health care laws, including:

  • billing for services which were not performed or medically necessary
  • billing for a more expensive service or item than was actually furnished, i.e. upcoding
  • double billing for the same medical service or item
  • giving or accepting something of value in return for providing medical services, i.e. kickbacks and
  • billing for ambulance runs to doctor appointments.

Health care fraud in Pennsylvania is prosecuted under the general Insurance Fraud statute which is found at 18 Pa. C.S.A. § 4117. A provider convicted of health care fraud faces a sentence of up to 7 year’s imprisonment and up to $15,000 in fines. Follow the law, but if you are accused of wrongdoing, call Mark Greenberg at 267-253-7933.

Not all allegations of health care fraud are prosecuted criminally. Some allegations are referred to the Department of Public Welfare or various professional health care licensing boards for administrative review. A health care practitioner or provider who loses his/her license will be prohibited from billing Medicaid and will be excluded from billing Medicare during the period of license suspension. Mark Greenberg can help the provider of Medicaid services in Pennsylvania to keep his/her license in the event of an administrative review.