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Glossary: Terminology in Health Care Fraud Investigations

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If you recently discovered that you are the focus of a federal healthcare fraud investigation, you are not alone. Each year, the Department of Health and Human Services (HHS), the Department of Justice (DOJ), and numerous other federal agencies investigate a growing number of hospices, home health companies, compound pharmacies, and other healthcare service providers for evidence of federal fraud. In many cases, their investigations focus on false claims and other fraudulent practices involving Medicare, Medicaid, Tricare, and other federal benefit programs.

When you find out that you are being investigated by the federal government, there are a number of important steps that you need to take right away. One of these is hiring a qualified healthcare fraud defense team to deal with the government investigators and prosecutors on your behalf. Another is to simply figure out why you are being targeted – although this often is not as easy as it sounds.

The following glossary may help you gain a better understanding of what is going on in your federal healthcare fraud investigation:

Federal Healthcare Fraud Terminology

1. Civil Monetary Penalties (CMP)

If your investigation is civil in nature, the government will likely seek civil monetary penalties (CMP) as part of your punishment. This is in addition to other financial penalties, such as restitution (discussed below).

2. Conspiracy

In many cases, federal prosecutors will allege that company executives or other individuals “conspired” to commit healthcare fraud. In layman’s terms, this is an accusation that two or more people worked together in order to take steps toward breaking the law.

3. Criminal Prosecution

If the government’s investigation reveals evidence of federal fraud, you could face criminal charges. One of the primary differences between a criminal prosecution and a civil enforcement action is that the penalties in a criminal case can include federal imprisonment.

4. False Claims Act

The False Claims Act is a federal statute that makes it illegal to knowingly submit a false or fraudulent reimbursement claim under Medicare, Medicaid, Tricare, or any other federal government benefit program.

5. Fraud

“Fraud” is a broad legal term that can be used in many different contexts. In the context of a federal healthcare-related investigation, it generally means that someone has deliberately and wrongfully deceived someone else (or the government) for personal financial gain.

6. Kickback

A kickback is a form of wrongful payment (money or in-kind) in exchange for someone else’s services. In the healthcare context, a common example is a doctor accepting compensation in exchange for recommending a particular medication. When this compensation is ultimately paid out of a federal program, it can constitute a violation of the False Claims Act, the Anti-Kickback Statute, and other federal healthcare laws.

7. Restitution

If you are found to have committed healthcare fraud, you may be required to repay the government any compensation that you received from federal benefit programs as a result of the fraudulent practice. This is known as “restitution.”

8. Stark Law

The Stark Law is a federal statute that prohibits certain types of physician referrals, particularly with respect to healthcare services paid for by federal programs.

9. Unbundling

Unbundling is the practice of billing related medical procedures separately in order to claim higher reimbursement rates from Medicare, Medicaid, and Tricare.

10. Upcoding

The term “upcoding” refers to submitting a reimbursement code for a more expensive service than was actually provided. Like unbundling, upcoding is a common form of healthcare fraud.

Speak with a Healthcare Fraud Defense Attorney at Oberheiden, P.C.

To get help with your federal healthcare investigation, contact Oberheiden, P.C. for a free, confidential consultation. Our experienced defense attorneys and former federal prosecutors handle federal healthcare investigations nationwide. Call (800) 701-7249 or send us your information online to speak directly with a senior member of our defense team today.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. Oberheiden, P.C. is a Texas LLP with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.
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