Worker’s Compensation Fraud Criminal Defense Attorneys
Dmitry Gurovich and Elon Berk are the managing partners of Gurovich, Berk & Associates, a criminal defense law firm that represents medical professionals. Mr. Gurovich and Mr. Berk have 38 years of combined experience defending their clients from Worker’s Comp Fraud, Medicare, and Medicaid Fraud charges. Unfortunately, these charges occur too frequently among providers, and most have absolutely no idea what they did to warrant such accusations. Prosecutors also routinely over-charge providers- they know they might have to settle for lesser charges after plea bargaining with the defense team. This is why it’s crucial to take action against any and all accusations. It’s in your best interest- your reputation, business, and liberty are on the line.
Mr. Gurovich and Mr. Berk have knowledge and experience of the medical industry. They are privy to the business structures of hospitals, pharmacies, and third parties involved in the industry. In addition to this strategic interaction with various medical-industry players, they are sensitive to the crucial nuances that many attorneys are oblivious to- such as the vast array of different provisions and policies specific to every insurance company. They have inspected governmental RAC and ZPIC audits with PI’s and analyzed hundreds of insurance claim forms. Mr.Gurovich has been invited to give presentations to providers. In these conventions, he is invited to inform medical professionals of crucial health care rules, regulations, and laws- which not knowing can cause them to intentionally “commit a crime.” In investigations, knowing these rules and when they were put into effect is a way to determine whether a provider actually committed the violation the government is charging him of. Mr. Gurovich and Mr. Berk’s experience and knowledge in the medical industry- on the industrial and atomic levels, ensure best possible defense will be formulated for you and your case. Give us a call. (818) 205-1555. We’re interested to hear your case.
Medical Professionals and Worker’s Compensation Fraud Charges
Knowing what is legal and what isn’t puts providers in a better position to avoid being accused of this heavily prosecuted crime. Worker’s compensation fraud is heavily targeted due to the substantial losses insurance companies incur. As a result, policyholders and taxpayers end up with more expensive premiums and deductibles. Insurance carriers and bureaucrats place increased political pressure on law enforcement to combat fraud because they believe that it has such a substantial impact on the industry. As a result, medical professionals are put under the microscope, and unfortunately, this can lead to serious, sometimes unwarranted allegations. This new effort against worker’s comp fraud has many legitimate providers reluctant to practice medicine and to bill as they once did.
Becoming familiar with what leads to criminal accusations should provide medical practitioners with confidence to practice medicine. Common worker’s comp fraud includes providing medically unnecessary services, falsifying billing statements, and soliciting and receiving kickbacks. Knowledge of the relevant laws should equip medical professionals with the necessary information to successfully run their practice. Our attorneys, Dmitry Gurovich and Elon Berk specialize in Nationwide Workers Compensation and Healthcare Fraud criminal defense. Should you have any questions after reading this article, please call us at (818) 205-1555.
What Constitutes the Crime?
Workers compensation fraud charges come up when a medical professional is accused of making a profit at the expense of the Workers Compensation Insurance Company. They can do this by either submitting false, fraudulent, or multiple claims, or by soliciting and accepting kickbacks, or both. The information is provided below:
Submitting False or Fraudulent Claims
One way providers can trigger charges is by providing medically unnecessary services or falsifying billing statements. Penal Code 550 makes it a crime to knowingly submit false claims to the Workers Compensation Insurance Company.
If you are accused of this, the prosecution must prove all the following elements:
- You submitted a false or fraudulent claim to the insurance company
- You knew the claim was false or fraudulent
- You intended to defraud the insurance company when submitting the claim
“Knowingly” is not limited to just actual knowledge; deliberate ignorance or reckless disregard for the truth or falsity of the information is enough.
False or Fraudulent Claims Include:
- Submitting claims for services that weren’t rendered
- Billing for a higher level of service than was provided (i.e. upcoding and unbundling)
- Prescribing unnecessary medications
- Ordering unnecessary patient tests
- Providing medically unnecessary procedures
What is Upcoding and Unbundling?
Upcoding refers to the practice of knowingly submitting inaccurate billing codes to the Worker’s Compensation Insurance company for a higher reimbursement rate. For example, an instance of upcoding is a physician performing a check-up on an injured employee and then submitting a billing code to the worker’s compensation insurance company indicating he performed a more complex procedure.
Unbundling occurs when a physician submits multiple CPT codes instead of submitting one inclusive code for a procedure. This is justified only if the physician spent more time in performing a service or if he performed other procedures, in which case the insurance company would rightly reimburse him for this additional time. However, if this is not the case and multiple codes are submitted, resulting in a higher, unjustified reimbursement rate, this “unbundled” billing code would be a false statement.
Medical necessity: Insurance companies only pay for what is “medically necessary,” and each insurance company’s plans and policies have different definitions for this. So, a provider who submits a claim for a procedure that wasn’t medically necessary, doesn’t meet the insurance’s company’s condition and is therefore not eligible for reimbursement.
In conducting the analysis of whether a criminal violation occurred, the provider’s intent is at issue and must be determined. The prosecution or investigative agency examines various factors, such as the necessity of the procedures billed, whether the patient’s file has complete records, patient’s medical history, the relationship between the provider and other individuals associated with the practice, and many other such factors to determine what the provider’s intent was at the time the bill was submitted.
Kickbacks and Worker’s Compensation Fraud
A kickback is basically a bribe. Penal Code 549 prohibits knowingly and willfully accepting or soliciting payment in exchange for anything of value. In other words, accepting or offering payment to another person or entity for business that will be reimbursed by the workers compensation company is a crime. There are exceptions of course, such as legitimate expenditures for marketing.
Payment is not limited to cash or even money. Anything of value, from free samples to referrals to cash, is considered payment.
Additionally, any claim made to the worker’s compensation insurance company resulting from such a kickback is a false claim.
Penalties for Submitting False or Multiple Claims (Penal Code 550)
It is a felony to submit false or multiple claims.
Felony probation and
- Two, three, or five years in jail
- A maximum $50,000 fine, or double the amount of the fraud (whichever is greater)
- Fines and jail
Penalties for Accepting, Soliciting, or Receiving Kickbacks (Penal Code 549)
Referring, soliciting or accepting business from someone who intends to commit insurance fraud is a wobbler.
If the prosecution chooses to charge you with a felony, you face:
Felony probation and
- 16 months, or 2, or 3 years in jail, or
- A maximum fine of $50,000, or double the amount of the fraud (whichever is greater), or
- Fines and jail
If the prosecution chooses to charge you with a misdemeanor, you face:
Misdemeanor probation and
- A maximum one year jail sentence, or
- A maximum $1,000 fine, or
- Fines and jail
Revocation of Medical License
Additionally, medical professionals may have their licenses revoked or suspended. Fraud charges should not interfere with the practice of medicine and should be fought to the fullest extent.
Legal Defenses to Worker’s Compensation Fraud Charges
Lack of Intent Defense – Submitting a false claim, by itself, is insignificant without establishing an intent to defraud. If the provider had a good faith belief that the procedure was medically necessary, it would negate criminal intent.
Mistake of Fact Defense – This defense applies when a false or duplicate claim was mistakenly submitted. Billing the insurance company for the wrong service could have been an honest mistake.