Anti-Medical Benefit Kickback Statute

The Anti-Kickback Statute that is defined under 42 U.S.C. § 1320a-7b makes it a federal crime for anyone to solicit or receive any kind of remuneration in exchange for a patient referral for services where a healthcare program pays for buying service or an item.

Alleged violations of this statute are very common and often start the following actions:

  • a federal government criminal investigation;
  • physician disciplinary proceedings; and
  • medical board actions.

In order for a prosecutor to pursue charges in an alleged anti-kickback scheme, they will review the case for two crucial elements of the crime, which must include remuneration between parties and illegal intent.

Anti-Medical Benefit Kickback Statute

Federal laws clearly lay out harsh penalties for any person who knowingly and deliberately request or receives any money or other type of financial compensation for referring somebody for treatment that is compensated by a federal health care program, which is commonly called a kickback or bribe.

Under 42 U.S.C. § 1320a-7b(b) states that you are guilty of a felony offense if you receive, pay, or bribe or kickback in exchange for referring a patient, or for purchasing, ordering, or arranging for purchase of any good or service that is compensable under any type federal healthcare program.

Our federal criminal defense lawyers are providing a closer look at the laws below.

Prosecution of the Federal Anti-Kickback Law

In reality, kickback prosecutions under 42 U.S.C. § 1320a-7b are typically filed against individual people who are profiting by signing up patients for a federally reimbursed healthcare program.

For example, a doctor pays a third-party a fee for each patient they refer to their office. Clearly, in this scenario, the doctor will make a larger than normal profit by having more patients that can treat and get a reimbursement, which is often a very profitable rate that is paid by the federal taxpayer.

The third-party source who referred all the new patients will also profit directly through a kickback from the doctor's office.  This statute also covers selling healthcare related goods and facilities, not just the medical services.

For instance, a pharmacist who pays a kickback to a referral that supplies patients with costly medical devices or prescription medications that are covered under a federal benefits program for a reimbursement.

In this example, the pharmacist could also face prosecution under the federal law defined under 42 U.S.C. § 1320a-7b. Further, readers should note that not all compensation received through a federally healthcare program rises to the level of a violation of the anti-kickback law.

The statute has exemptions; such as discounts or reductions in price by the provide as long as the discount is disclosed properly and reflected in the claims for reimbursement.

Put simply, the provisions within 42 U.S.C. § 1320a-7b are primarily directed at illegal patient referral and kickback activity discussed above. It does not generally target legitimate healthcare providers who actually provide valid medical services that are compensated by federal tax dollars.

What is Policy Behind Medical Insurance Fraud Kick-Back Cases?

Right now the medical system has got a big problem as it relates to people basically bidding for patients. So, what's happening is, you have a patient who can get money from the government. If you're a doctor, you have to refer that patient to a lot of these facilities that are taking care of them.

So, what ends up happening is, you have these people who are basically telling the facilities that they give them a kick-back, they will refer the patient to them.

For example, they can say it's $500 in order for the patient to be referred to them and then the doctors are also getting kick-backs in situations.

So, what happens is, you don't get the best medical healthcare, because instead of basing it on how good the people are, a lot of times people are being referred based on money that's being kicked-back. Obviously, this is illegal. This is where the crime comes in. This is what the government is trying to stop.

The bottom line is, they want to make sure that the person who needs medical services is protected, their medical costs aren't sky-high, the government doesn't end up paying extra money because of what's going on.

Defense Strategies for Anti-Kickback Violations

So, if you or a loved one is tried in these anti-kick-back schemes related to medical insurance fraud, you should pick up the phone right away. Sometimes you don't fit within the gambit of what they're attempting to claim you were involved with.  Sometimes there's another side to the story and the government is only looking at it from a slanted review.

Sometimes these investigators that are involved with these insurance fraud cases don't have the full picture, don't listen to what other people say, don't investigate the other side of the story.

Defense Strategies for Anti-Kickback Violations

That's where I come in as your criminal defense attorney.  I'm going to look at everything.  We're going to talk about it and we're going to make a decision whether or not you're:

  • going to fight your case, or
  • whether or not your case is the type of case that we should sit down with the government, get a mitigation package together and resolve it.

A lot of times they're just looking for people to stop being involved for paying for patients. We can ensure the government that you're not going to be involved in that.  If there's any money that has been paid that shouldn't have been paid, we can pay that money back.

We can get character letters.  We can show that you're the type of person that can be reformed. On the other hand, if you're innocent and you didn't do anything wrong and the government has it wrong, then we've got to sit down and talk about that and get our defense plan together so you can defend your case.

So, if you're charged with any type of medical insurance fraud related to kick-backs, you've come to the right place. I've got a lot of experience, both at the state and federal level.

Pick up the phone.  Make the call.  Ask for a meeting with Ron Hedding. Hedding Law Firm is based in Los Angeles County and we serve clients in the state of California and throughout the United States. We offer a free case evaluation by calling 213-542-0994, or fill out our contact form.

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