Anti-Medical Benefit Kickback Statute

The Anti-Kickback Statute, 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 a service or an item.

Alleged violations of this statute are common and often start a federal government criminal investigation, physician disciplinary proceedings, and medical board actions.

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

Federal laws impose harsh penalties for anyone who knowingly and deliberately requests or receives any money or other type of financial compensation for referring somebody for treatment compensated by a federal health care program, commonly called a kickback or bribe.

42 U.S.C. § 1320a-7b(b) states that you are guilty of a felony offense if you receive, pay, bribe, or kickback in exchange for referring a patient or for purchasing, ordering, or arranging for the purchase of any good or service that is compensable under any type of federal healthcare program. Our federal criminal defense lawyers are reviewing 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 individuals who profit by signing up patients for a federally reimbursed healthcare program.

Anti-Medical Benefit Kickback Statute

For example, a doctor pays a third party a fee for each patient they refer to their office. In this scenario, the doctor makes a larger than normal profit by having more patients who can be treated and reimbursed, which is often a very profitable rate the federal taxpayer pays.

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 medical services.

For instance, a pharmacist 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 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 federal healthcare program violates the anti-kickback law.

The statute has exemptions, such as discounts or price reductions by the provider, 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 the illegal patient referral and kickback activity discussed above. They do not generally target legitimate healthcare providers who actually provide valid medical services that are compensated by federal tax dollars.

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

Currently, the medical system has a big problem with people bidding for patients. So, if you have a patient who can get money from the government, you must refer that patient to many of these facilities that care for them.

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

For example, they can say it's $500 to refer a patient to them, and then the doctors also get kickbacks in situations.

So,  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 ensure that the person who needs medical services is protected, their medical costs aren't sky-high, and the government doesn't end up paying extra money because of what's happening.

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 immediately pick up the phone. 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 only looks at it from a slanted review.

Sometimes, investigators involved in insurance fraud cases don't have the full picture, don't listen to what other people say, and 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 decide whether or not you're:

  • going to fight your case, or
  • whether or not your case is the type of case, 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 paying for patients. We can ensure the government that you're not going to be involved in that. If any money has been paid that shouldn't have been paid, we can pay that money back.

We can get character letters and show that you're the type of person who 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 kickbacks, you've come to the right place. I have extensive experience, both at the state and federal levels.

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 California and throughout the United States. Call 213-542-0994 or fill out our contact form to offer a free case evaluation.

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