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Health Insurance Fraud

Health Insurance Fraud

Attorney David M. Dudley has been successfully defending clients accused of health insurance fraud and other types of insurance fraud for decades. This type of fraud is considered a white-collar crime, meaning that no violence or threat of force is involved in committing the crime. By contrast, blue-collar crimes do involve violence.

What is Health Insurance Fraud?

Health insurance fraud may be committed by a health insurer or by the person who is insured. The latter may be a patient or a doctor, that is, a member of an insurance plan or a provider of health care services. One example of health insurance fraud is if the doctor or patient intentionally submits false claims to the insurance company to be paid for services that were not provided.

Other examples of fraud by an insured doctor or institution include:

  • Billing for services, procedures or supplies that were not provided by the doctor or health care institution
  • A doctor doing unnecessary services or tests on a patient
  • Telling the insurance company that the fee charged was the usual fee when it actually was lower because the doctor reduced the fee for an uninsured patient
  • Submitting separate claims for procedures that normally are billed together; an example would be a surgeon who operates on three fingers but separates the bill into three separate charges (depending upon the complexity of the surgery, charging for three procedures might be legitimate)
  • Double billing, charging for the same service twice
  • Upcoding, increasing the insurance code to charge more for a more complex procedure than the one that actually was done
  • Receiving kickbacks for patient referrals
  • Obtaining patients’ Medicare numbers to fraudulently submit bills
  • Billing insurance companies for non-existent injuries
  • Misrepresenting a diagnosis or the procedure performed

How Can Insurance Plans be Considered Fraud?

Some types of health insurance fraud perpetrated by members of an insurance plan include:

  • Providing false information on an application or a claim form
  • Forging or selling prescription drugs
  • Taking advantage of transportation benefits when transportation is not for medical care
  • Loaning to or using an insurance card from someone else

Experienced Federal Crimes Lawyer

Mr. Dudley’s experience and skill in defending clients accused of health insurance fraud and other types of insurance fraud have led to many reduced sentences for defendants as well as an outright dismissal of cases. His almost unmatched degree of experience has earned him a reputation as one of the top federal crimes lawyers in the nation.

Mr. Dudley’s services are usually less expensive than those of large corporate firms that charge high hourly fees for their work. He determines a flat fee for his work which covers all of his services so you know what you’re paying upfront.

Insurance Fraud: Selected Case Results

  • U.S. v. N.S.: A medical doctor was indicted federally for overcharging a government health insurance agency by more than $100,000 for services he had provided to several patients. Although the defendant was convicted at trial, he received a sentence of only 24 months for his misconduct.
  • P. v. E.D.: While working in the accounting department of a medical clinic that provided free and discounted services to the poor, the defendant embezzled $1,200,000. Consequently, the district attorney charged her with several felony fraud counts. After producing a psychiatric report and other documents that demonstrated that the defendant engaged in the unlawful conduct only to support a massive gambling addiction, the defense was able to obtain a disposition under which she received a prison term of only four years.
  • U.S. v. R.S.: Paying retail clerks and medical receptionists to scan the credit cards of customers, the defendant used the information obtained to manufacture counterfeit credit cards. When he was indicted federally, the government claimed that he had caused losses of over $1,000,000 to cardholders and financial institutions. After reaching a plea bargain that left open the issue of aggregate loss, Attorney Dudley convinced the court to apply a reasonable doubt standard to the government’s claim of how much money his conduct caused victims, even though the court was not legally required to use such a high standard. Applying that standard of proof, the court found that the government could only demonstrate losses of $420,000. The court then departed slightly downward from the resulting guideline range to impose a sentence of 46 months, 41 months lower than the government’s recommendation.
  • U.S. v. C.V.: The defendant was the office manager for several health clinics that allegedly defrauded the government and numerous health insurance companies of over $42,000,000 dollars. The United States Attorney named her as a principal conspirator in a multi-count indictment. After litigating numerous pre-trial motions, the defense eventually negotiated a disposition for approximately 22 months of TIME SERVED.
  • P. v. H.W.: The defendant, who owned an insurance agency and the office building from which the agency did business, was accused of attempting to bribe a city official to avoid having to spend money for substantial construction necessary to place the building in compliance with city codes. After the defense presented its claim at a preliminary hearing that the prosecution could not prove that the object which the defendant allegedly offered to the public officer had any market value, the district attorney agreed to DISMISS all felony charges.
  • P. v. M.R.: As the manager of a law office that had purportedly presented millions of dollars in fraudulent liability claims to auto insurance companies, the defendant was charged with felony insurance fraud. Although others in the conspiracy eventually pleaded guilty to offenses that sent them to state prison, the defendant obtained a sentence of PROBATION with no period of incarceration.
  • P. v. J.L.: The defendant was allegedly a major “capper” in an automobile insurance fraud ring. Although he was facing numerous felony fraud charges carrying potential state prison sentences, the defendant received a PROBATIONARY sentence without incarceration.