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In Oklahoma, Medicaid fraud is defined as the intentional act of misrepresenting or concealing information in order to get payments or benefits from the Oklahoma Medicaid Program. Medicaid fraud is a violation of state and federal law and is prosecuted under statutes 63 O.S. § 5053.1 and the Medicaid False Claims Act. Individuals or organizations facing charges of healthcare fraud are encouraged to contact a criminal defense attorney with experience navigating the investigation and trial process for fraud in Oklahoma.
Medicaid fraud is categorized into two categories including provider and recipient fraud. Providers can be charged for fraudulent acts such as billing for unnecessary services, billing for services not provided, unbundling, upcoding, and collusion. Recipients' charges include helping a doctor file false claims, altering prescriptions, and altering or duplicating a Medicaid ID. The penalties for those convicted include fines up to $10,000 and prison sentences up to three (3) years.
A Medicaid fraud defense attorney provides legal representation for medical providers, Medicaid beneficiaries, and government employees who who are under investigation or facing charges of attempting to defraud the Oklahoma Medicaid Program. Our attorneys review evidence, identify weaknesses in the prosecution's case, advise our clients during audits or interviews, and negotiate with state or federal investigators.
Criminal defense strategies for medical providers accused of Medicaid fraud focus on proving there was no attempt to defraud as well as challenging the accuracy of evidence such as billing records or relevant documentation.This includes demonstrating that billing discrepancies were caused by clerical errors, improper coding, or due to errors made by a third-party billing service. Attorneys present evidence such as such as patient treatment records, CMS-1500 or UB-04 claim forms, internal billing logs, and provider-payer correspondence to demonstrate that all billed services were medically necessary and provided in full. In cases where coding errors are alleged, coding audit reports, CPT/ICD coding guidelines, or billing manuals may be introduced to show that the provider's documentation practices adhered to accepted industry standards.
Medicaid fraud is categorized into two types including provider and beneficiary fraud. Provider fraud includes illegal billing practices or deceptive acts committed by healthcare professionals or organizations such as doctors, hospitals, nursing homes, home health care agencies, medical transport companies, pharmacies, laboratories, medical equipment manufacturers, and pharmaceutical companies, in an attempt to collect illegitimate payments from the Oklahoma Medicaid Program. Beneficiary fraud involves Medicaid recipients who falsify or withhold information in order to receive money or benefits they are not legally entitled to.
Healthcare providers under the Oklahoma Medicaid Program are subject to potential criminal charges for a wide range of activities or omissions. Those providing goods and services under the Program can be charged when they:
To protect your name it is essential that you speak with an experienced attorney if you've been notified of charges.
Penalties for Medicaid and healthcare fraud are not limited to only participants receiving assistance and persons providing the assistance. Those individuals that work with the agencies associated with providing benefits to Medicaid recipients can also face criminal liability.
There are situations in which individuals on the “inside” assist providers or recipients in their misrepresentations or omissions by turning a blind eye. Individuals engaged in such activity will usually receive a kickback or some other payment for their assistance. In that scenario, felony charges could be filed. However, that is not always the case.
Consequently, employees of the State Department of Health, the Department of Human Services, and the Oklahoma Health Care Authority who knowingly or willfully fail to promptly report a violation of the Medicaid Program can be charged with a misdemeanor as well.
The punishment range for these acts can result in either misdemeanor or felony charges as well depending on the amount gained as a result of the fraud. When the aggregate amount of payments illegally claimed or received is less than $2,500.00, the provider will face a misdemeanor charge and up to one (1) year in county jail. If that amount is $2,500.00 or more, the provider will be charged with a felony and upon conviction face up to three (3) years incarceration.
For the purposes of Medicaid Fraud, a participant or provider shall be deemed to have known that a claim, statement, or representation was false if the person knew, or had reason to know, of the falsity of the claim, statement, or representation. This means that a person need not know the exact nature of the false or fraudulent misrepresentation or omission, so long as the person should have known the nature of the misrepresentation and or omission.
Don't answer any questions until you have a lawyer on hand as your answers can and will be used against you. To speak to a fraud expert contact the lawyers at the Law Offices of Adam R. Banner, P.C. today.
In order to be charged with this crime, any person need only make a claim the person knows to be false, either in whole or in part, by commission or omission in connection with the Program. Participants in the program (as opposed to providers) can also be held criminally liable when they make a false representation or statement while attempting to obtain a service or good provided under the Program.
