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Healthcare Fraud in Illinois

Healthcare fraud is rampant in the State of Illinois. It is a fraud offense that doesn't get as much attention as other fraud crimes like identity theft or credit card fraud because in these cases, it's not the consumer who is the victim, but usually a large company or the government. Healthcare fraud is a serious allegation and one that must be met with a strong defense. For one, the alleged victim (e.g., big health insurance companies or the government) will use all its resources to aid the prosecutor in a conviction. That's a lot of power. You must be able to meet that kind of power with the same, and the only means to do so is via an experienced healthcare fraud defense attorney.

At Dolci & Weiland, our fraud attorneys are committed to a strong, thoughtful healthcare fraud defense. We represent clients throughout DuPage County and Cook County. Contact us as soon as possible if you have been charged or are under investigation for healthcare fraud. The sooner our investigation can begin the sooner your defense can begin.

Understanding Healthcare Fraud in Illinois

Healthcare fraud occurs when a person or entity submits data to a healthcare provider or other healthcare system intentionally to turn a profit or benefit in some way. These crimes can be charged under state and/or federal law, depending on the circumstances and facts surrounding the fraud.

Alleged healthcare fraud offenders are typically medical professionals, providers, or practitioners, but they can also be a 

  • medical institution
  • medical facility
  • a patient
  • a health insurer
  • A nurse
  • A pharmacist
  • Hospital
  • Hospital systems
  • Clinics
  • Home healthcare companies
  • Medical billing and coding companies. 

Offenders devise plans or schemes to report false information into the healthcare system to gain a financial benefit. As such, this crime is a crime of intent. You must have intentionally or knowingly committed the act.

Healthcare fraud crimes can be charged under a number of Illinois laws, including statutes like the Mail Fraud and Wire Fraud Statute and the Anti-Kickback Statute

Examples of Healthcare Fraud in Chicago

Healthcare fraud is a multi-billion dollar industry in the United States. It is committed on a small scale as well as a large scale. The ways to commit it are also just as wide and diverse. To better understand what healthcare fraud is and if it could apply in your unique situation, here are some examples of what various members of the healthcare industry may do to defraud the system for his, her, or its own benefit.

Example 1: Hospices Committing Healthcare Fraud

A hospice enrolls patients in services that the patients do not require or that do not match the needs of their illness. The hospice files claims for the same and Medicare and/or Medicaid pays the hospice for the treatment. A hospice may also file claims for procedures that were never even performed and then get reimbursed by Medicaid or Medicare. These are all forms of healthcare fraud committed by a hospice or an employee or owner of a hospice.

Example 2 Pharmacies Committing Healthcare Fraud

Pharmacies can set up a plan with local doctors and employees at doctor offices to obtain a higher volume of prescriptions. The pharmacy may bribe or pay kickbacks to these doctors and employees when they increase the number of prescriptions written and sent to them. 

Example 3: Hospitals Committing Healthcare Fraud

Like hospices, employees or doctors at hospitals may claim or prescribe certain procedures that are not performed or are not necessary to defraud Medicare and Medicaid. Hospitals have also been known to offer kickbacks to doctors to increase referrals to the hospital.

Example 4: Patients Committing Healthcare Fraud

A patient may fake an illness or medical condition to receive specific medicine that he or she can later sell on the black market for a profit. A patient may also, among other things, use someone else's insurance to get healthcare services or falsify information on a medical claim to get more money reimbursed.

Example 5: Doctors Committing Healthcare Fraud

Doctors may accept bribes or kickbacks from pharmacies or hospitals to benefit themselves. They may also double bill, prescribe unnecessary medicine or procedures (like x-rays or lab tests) or intentionally upcode services or medical procedures by lying about the time spent with the patient or exaggerating a medical service. 

Illinois Penalties for Healthcare Fraud

Several years ago, Illinois increased its penalties for healthcare fraud. What penalty a convicted person receives is dependent on the actual charges, the total value obtained due to the fraud, the severity of the charges, and the number of charges, among other factors. Generally, a healthcare fraud charge is a Class 4 felony, which is punishable by up to three years in prison and fines of up to $25,000 for individuals and $50,000 for corporations. A person or entity may also be subjected to civil penalties and federal charges.

A person charged and convicted under the Mail Fraud and Wire Fraud and Anti-Kickback statutes can also face a maximum potential penalty of 20 years of imprisonment with the potential of life imprisonment if someone dies as a result of the violation.

Defenses to Illinois Healthcare Fraud Charges

There are defenses to healthcare fraud charges in Illinois. Common defenses include:

  • Lack of Evidence. In many cases, coding may have to be analyzed and without the proper analysis or other lack of evidence, the ability to prove the offense beyond a reasonable doubt may be limited.
  • Lack of Intent. You may have made an honest mistake when filling out a form and/or filing a claim.  As a crime of intent, you must have the requisite mental state to commit the crime or else no crime was committed.
  • Mistake of Fact. The State may have made a mistake and understood the facts. If the facts are wrong, it may indicate your innocence.
  • Mistaken Identity. The State may have gotten it wrong who actually committed the offense. Maybe it wasn't the doctor of a general practitioner office but the nurse who works there.
  • Statute of Limitations. Charges of healthcare fraud must be filed within a certain period. In Illinois, it's typically five years for fraudulent concealment. For federal charges, it can vary between six and ten years, depending on the facts and allegations.

Contact Healthcare Fraud Defense Attorneys in the Greater Chicago Metro Area Today

A conviction of a healthcare fraud crime can be serious in terms of court-order penalties. But worse are the penalties imposed by society after you have completed your sentence. Your good name, your reputation, and possibly your livelihood can be ruined. As an ex-felon, too, you may lose the right to vote and the right to own and use a firearm.

The collateral consequences of this type of conviction can be enormous and life-changing. It's is important to fight the charges to get them dismissed or reduced or to win an acquittal at trial. An experienced healthcare fraud attorney can help you. Contact Dolci & Weiland today if you have been charged or if you know you are under investigation for a healthcare fraud crime in DuPage County or Cook County, Illinois.