This document is from John P. Pierce of Themis PLLC law firm about healthcare fraud. It outlines what constitutes healthcare fraud, how the government is cracking down on it through increased investigations and prosecutions, and the criminal penalties and fines that can result from being found guilty of healthcare fraud offenses. It advises readers who believe they may be under investigation to contact an attorney.

2. (202) 567-2050
http://www.themis.us.com/
THEMIS PLLC

3. TEL: (202) 567-2050 http://www.themis.us.com/
Billing Crime & Punishment
5/17/12
John P. Pierce
Themis PLLC
2305 Calvert Street, NW
Washington, DC 20008
(202) 567-2050
JPierce@Themis.US.com

4. TEL: (202) 567-2050 http://www.themis.us.com/
What is Healthcare Fraud?
 Simplified Criminal Elements
- A scheme to obtain money from a health care benefits program
by making false or fraudulent representations of material facts
- Willfully committed and intended to defraud
 What that means to you
- Scheme
- Health care benefits program
- False or fraudulent
- Willfully committed and intended to defraud

5. TEL: (202) 567-2050 http://www.themis.us.com/
What is the Scope of the Problem?
(In the eyes of the Government)
• False Claims Act – civil
- $30 billion recovered since 1986
- 28% of $30 billion recovered during Obama Administration
• The trend in criminal cases
•http://www.justice.gov/opa/pr/2012/May/12-ag-568.html;
•http://www.justice.gov/iso/opa/ag/speeches/2012/ag-speech-120502.html;
•http://www.justice.gov/criminal/pr/speeches/2012/crm-speech-
1205021.html

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How is Government Bringing the Heat?
• The Medicare Fraud Strike Force
• Health Care Fraud Prevention & Enforcement Action Team
• Coordination Among Federal, State and Local Agencies

7. TEL: (202) 567-2050 http://www.themis.us.com/
What Investigative Techniques are Being Used?
• Computer Analysis
• Whistleblower
• Gumshoe
• Undercover Operatives
• Wiretaps

8. TEL: (202) 567-2050 http://www.themis.us.com/
How Will YOU Know About an Investigation?
• Telephone call
• Letter of inquiry
• Agency interview
• Subpoena
• Search warrant
• Complaint
• Indictment

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What Should You Do?
(psst! . . . CALL AN ATTORNEY!!!)

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With What Crimes are Billers/Providers Charged?
 Health care fraud 18 USC 1347 (or wire/mail fraud)
 Conspiracy
 Money laundering
 Anti-kickback statutes
 Aiding and abetting
 False statements 18 USC 1001

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With What Punishment?
 Federal
- Maximum 5 years/$250,000 For Each Violation Consecutively
- More Likely:
 $10,000 in claims : 6 – 12 months in prison
 $70,000 in claims: 15 – 21 months in prison
 $200,000 in claims: 27 – 33 months in prison
 $1,000,000 in claims: 41 – 51 months in prison
 And UP
 State – varies
 Accompanying administrative implications – severe
- Compliance plan
- Monitoring program
- Debarment – the greatest punishment

12. TEL: (202) 567-2050 http://www.themis.us.com/
How Do I Protect Myself and My Organization?
• Compliance
• Compliance
• Compliance
• Preventive
• Proactive
• Prudent

13. TEL: (202) 567-2050 http://www.themis.us.com/
Questions?
John P. Pierce
Themis PLLC
2305 Calvert Street, NW
Washington, DC 20008
(202) 567-2050
JPierce@Themis.US.com
Billing Crime & Punishment
5/17/12

14. (202) 567-2050
http://www.themis.us.com/
THEMIS PLLC