Understanding Louisiana Healthcare Fraud Laws and Regulations

It can be hard for healthcare providers to understand Louisiana healthcare fraud laws and regulations. Most want to do the right thing. Missteps can happen even when there’s no intent to deceive. By breaking down what counts as fraud, providers can protect their practices.

What Is Healthcare Fraud?

Healthcare fraud happens when someone lies or hides facts to get money from a healthcare program. It covers a wide range of acts. Some people bill for services that were never given. Others charge for one thing but provide something else.

Fraud does not need to be significant to be taken seriously. A small act done many times can still lead to major consequences. If the act was planned and carried out on purpose, it can lead to a criminal case.

The law looks at intent. A mistake or oversight is not the same as fraud. The line between human error and a crime can shape the outcome of a case.

Common Triggers for Investigation

Some patterns raise concern and lead agencies to open a healthcare fraud case. Common triggers include:

• Unusual billing: If a clinic or provider bills much more than others in the same field, that can lead to a review. Algorithms used by Medicaid and Medicare track this over time.
• Frequent use of high-value codes: Repeated use of expensive codes may raise concern. Complex tests or surgeries may be necessary in some cases, but not all of them. Even if the care is real, the system may flag it.
• Whistleblower claims: Employees or former workers sometimes report fraud. These claims carry weight if the person has access to records. A whistleblower may also file a claim in federal court.
• Patient complaints: When a patient notices services on a bill they never received, they may call the insurer or the Attorney General’s Office. This can lead to a formal inquiry.
• Random audits: Some providers are randomly chosen for audits. If the audit reveals major issues or missing records, the matter may be passed to fraud investigators.

In 2018, 73.4% of those found committing healthcare fraud were sentenced to prison. Investigations may start small but can grow quickly.

Role of Intent in a Fraud Case

Intent is one of the most important parts of any fraud case. Prosecutors must prove that the person knew the claim was false and sent it anyway. Without intent, the act may not meet the legal definition of fraud.

Intent can be shown in different ways. Written or verbal communication can show intent to submit false claims. Other clues can include random changes to records or hidden documents.

A good defense can challenge the idea that the act was done on purpose. Billing errors or poor training can cause mistakes. Without proof of intent, a fraud charge may not hold up.

Billing mistakes happen in every practice. These errors may lead to overbilling or duplicate claims, but they don’t always rise to the level of fraud.

Auditors and investigators try to sort out these situations early on. If a provider has systems in place to catch errors, that can help their defense. However, repeated issues or ignored warnings may point toward intent.

Penalties and Consequences

The penalties for healthcare fraud vary based on whether they are at the state or federal level. For federal charges, a prison term can potentially go beyond five years. State charges may bring shorter terms but still leave a mark.

Civil cases are entirely separate and can result in monetary damages. These can include double or triple the value of what was paid out. Courts may also prevent a provider from being able to bill Medicaid or Medicare anymore. This can financially restrict a medical practice. Licenses might be revoked, and the reputation of the provider may be affected.

Why Do I Need an Attorney?

A defense attorney helps protect you when facing fraud charges. This starts with reviewing records and the charge itself. The attorney can look for gaps in the government’s case, especially where intent is hard to prove.

Attorneys may deal with state or federal agencies directly. They may try to resolve the case without a trial, which could mean a dismissal or a lower charge. If the case goes to court, an attorney can present evidence and question witnesses.

FAQs

Q: What Qualifies as Healthcare Fraud Under Louisiana Law?

A: Healthcare fraud under Louisiana law happens when someone gives false information to get money from a healthcare program. Common examples include billing for services not provided or using the wrong codes to raise payment. Even small lies on billing forms can lead to a fraud case if done on purpose.

Q: Can a Person Face Civil and Criminal Charges for Healthcare Fraud?

A: A person can face civil and criminal charges for healthcare fraud. A civil claim may ask for repayment and extra penalties. A criminal charge can lead to jail time and a criminal record. The two types of cases can run at the same time or one after the other. For criminal charges, prosecutors must show that the person intended to commit fraud.

Q: What Is the Penalty for Healthcare Fraud in Louisiana?

A: The penalty for healthcare fraud in Louisiana depends on the severity of the fraud. Someone found guilty can face time in jail. Sentences may range from months to many years. Fines can also reach hundreds of thousands of dollars. People may lose the right to bill Medicare or Medicaid. A healthcare license can be revoked.

Q: What Actions Trigger a Medicaid Investigation?

A: Actions that trigger a Medicaid investigation include unusual patterns in billing. Sometimes, audits are completely random. Patients can also file a complaint. A whistleblower from inside a clinic or office can start an investigation. Once the government receives a report, it can review the facility and its billing activity. There were 69,425 reported cases in 2018.

Prevent Long-Term Damage With The Law Office of Joshua S. Guillory

Mistakes in billing or documentation don’t always mean fraud. At the same time, however, the median loss for each case of fraud in 2018 was $1,048,375. A steady legal hand can make a difference for professionals trying to move forward. Schedule a consultation with The Law Office of Joshua S. Guillory to include your voice in the proceedings.