Last year, a federal jury in Texas convicted a doctor who owned and operated a Houston Medical Clinic of medical fraud. The jury found her guilty of participating in a $16 million fraud scheme involving Medicare. She signed false and fraudulent medical documents and “plans of care,” purporting to offer home health services.

Medical fraud has been on the radar of Texas authorities and the FBI in recent years. Law enforcement has seen an uptick in medical fraud and is working to combat it. The defendant owned and operated a medical facility called HMS Health and Wellness Center, PLLC. Most of her charges related to fraudulently charging for services she did not render or overcharging for services she did render. She was convicted of several federal crimes, including the following:

  • One count of conspiracy to commit healthcare fraud
  • One count of conspiracy to solicit and receive healthcare kickbacks
  • Two counts of making false statements related to healthcare matters


Medical Fraud Often Includes Medicare Fraud

The defendant made it appear that her patients were qualified for and received home healthcare services through Medicare. Clients did not receive home healthcare services. In some cases, members in the Medicare fraud conspiracy ring paid the patients to receive the services they did not need or were medically unnecessary. In other cases, the doctor never even provided the services. The prosecution also offered evidence that the doctor often required the home healthcare agencies to pay her an illegal kickback. She then disguised the kickback amount as a copay. In exchange, the defendant certified and re-certified patients, falsely claiming that they needed these home healthcare services.

According to the evidence presented at trial, the defendant would not release the home healthcare paperwork until the marketers or home healthcare companies paid her the illegal kickback. She filed false and fraudulent Medicare claims and received over $300,000 in illegal kickbacks. Federal prosecutors have charged many other people involved in this fraudulent Medicare scheme, including patient recruiters, other doctors, nurses, marketers, and administrative staff. The Medicare Fraud Strike Force within the US Attorney’s office for the southern district of Texas investigated this case.


Law Enforcement Has Been Cracking Down on Medical Fraud

The case mentioned above is just one example of multiple high-profile healthcare fraud cases that have come to light in recent years. The federal government has used its Medicare Fraud Strike Force to investigate healthcare fraud across the country. The agency has 15 strike forces that operate in 24 districts. As a result of their investigation, over 4,200 defendants have been charged for Medicare fraud that has resulted in over $19 billion in stolen assets. The federal government has been taking steps to hold people accountable for Medicare fraud and other types of healthcare fraud.


Texas is Also Cracking Down on Medical Fraud

The Texas Attorney General has also made it known that their office plans to crack down on medical fraud and abuse. Healthcare fraud involves deceptive practices in the healthcare industry that lead someone to earn an excessive profit. Many healthcare fraud schemes cost the nation billions of dollars, resulting in higher out-of-pocket expenses and premiums for healthcare consumers. The Texas Attorney General defines healthcare fraud as the “deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.”


Fraudulent Health Insurance and Medical Billing

One of the most common types of medical fraud involves fraudulent health insurance in medical billing. This type of fraud occurs when a healthcare provider or individual deceives a medical insurance company to receive more money than the service cost. Medical billing and health insurance fraud often include the following:

  • Billing an insurance company for services that were not performed
  • Billing an insurance company for a more expensive service than the doctor performed, a process called upcoding.
  • Billing the insurance company at every stage of a medical procedure as if it was a separate procedure, a process also called unbundling
  • Claiming that a patient has a false diagnosis to justify medical procedures that are not necessary
  • Accepting a financial kickback for patient referrals
  • Waiving patient deductibles or copays and over billing and insurance carrier


Drug Fraud and Abuse

Another common type of medical fraud involves prescription medication fraud. Doctors have a right to prescribe medicine, and they sometimes have used that right to try to make extra money on the side. There are three main types of drug fraud and abuse. The first type involves drug pricing fraud. When a doctor prescribes unnecessary medication to a patient to profit from the sale, he or she has engaged in drug pricing fraud. In other cases, doctors or pharmacists will knowingly try to get their patients to take expired, altered, stolen, or fake prescription drugs. Finally, doctors could choose not to administer the medication a patient needs but instead keep it to sell for their personal profit.


Medicaid and Medicare Fraud

In the case mentioned above, the doctor was engaged in health insurance, medical billing fraud, and Medicare fraud. Medicaid and Medicare fraud involves billing for services that the patient does not need or never received. Doctors do this in an attempt to pocket Medicaid and Medicare healthcare reimbursement funds for themselves. Health insurance and medical billing fraud involves falsifying a patient’s diagnosis or treatment to steal more money.


Contact a Fort Worth Healthcare Fraud Lawyer Today

If you are facing Healthcare fraud charges in Texas, you need an experienced criminal defense lawyer on your side. Attorney Steve Jumes has successfully represented many clients throughout the Fort Worth and Plano area in high-profile Healthcare fraud cases. He will thoroughly investigate your case and mount a skilled legal defense on your behalf. He understands state and federal laws related to healthcare fraud and will use every avenue available to argue for your innocence. Contact Law Offices of Steven Jumes today to schedule your free initial consultation.