Texas Fraud Laws: Healthcare Fraud

Healthcare providers, insurers and medical organizations are held to high ethical standards when they treat patients and interact with insurers. They are expected to be honest and avoid committing fraud.

Despite this high standard, incidences of healthcare fraud continue to be prevalent in Texas. Individuals who are found guilty of this crime often face serious legal repercussions that can include prison sentences and expensive civil fines.

What is Healthcare Fraud?

Healthcare fraud is a criminal offense that can be committed by a host of individuals, most often healthcare providers like primary care doctors, nurses and surgeons. However, insurers and pharmacies can also commit this crime. Even patients themselves have been known to engage in healthcare fraud.

Nonetheless, it is a serious offense that can be charged at the federal level and be defined as a felony, depending on the amount of money that the offender or offenders steal. Under Texas law, it is defined as knowingly and purposely executing a scheme or plan to defraud a healthcare benefit program of benefits and money or obtaining benefits from the program through false means, false representations or fraudulent promises.

In essence, if someone lies to receive benefits, money or any assets that a healthcare benefits program owns or has access to, he or she commits healthcare fraud. This person can be charged with either a misdemeanor or felony and risk penalties that include going to jail or having to pay steep monetary fines.

Have you been accused of healthcare fraud?
Contact attorney Greg Tsioros today »

Types of Healthcare Fraud 

Healthcare fraud can take a number of different forms. All of them are open to being prosecuted under Texas state law and can result in the offender being sent to prison and fined heavily by the state.

The most common type of this offense involves falsifying diagnoses to receive more money from an insurer or healthcare benefits program. The false diagnosis of a patient may be used to justify procedures that are not necessary or did not ever take place in a bid to get a higher payment in return. 

Another form of healthcare fraud involves using another person’s personal identity information fraudulently. If a person uses someone else’s name, address and health insurance information to receive medical care, he or she can be charged with healthcare fraud.

Billing for services rendered is yet another example of healthcare fraud that results in the loss of millions of dollars each year. Healthcare providers who bill insurers or patients for procedures that never took place can be charged with this offense. 

Other examples of healthcare fraud include:

• Upcoding, or billing for more expensive services than those actually provided
• Unbundling, or billing for separate facets of a procedure to get higher insurance payment
• Accepting kickbacks for patient referrals
• Waiving patient co-pays or deductibles and then over billing the insurer

This crime can also extend to drug fraud and abuse. For example, if a doctor dishonestly prescribes unnecessary medications for a patient so he or she can profit from the sale, this doctor can be charged with healthcare fraud.

Likewise, a doctor can be charged if he or she pushes stolen, expired or counterfeit medications to a patient. He or she can also be charged if the doctor does not give the patient medication but keeps it to sell it for profit.

Penalties for Healthcare Fraud

Texas state law allows for a variety of punishments for those who are found guilty of healthcare fraud. The types of punishment that offenders receive will largely depend on the amount of money or benefits that they defrauded from the benefits program and whether or not they have prior healthcare fraud convictions.

A person can be charged with a Class C misdemeanor if the amount of money stolen is $100 or less. The typical punishment for this level of offense is a fine of no more than $500.

Healthcare fraud is charged as a Class B misdemeanor if the amount of money stolen is more than $100 but less than $750. The penalties for this Class B offense is a fine of up to $2000. The convicted person may also be sentenced to up to 180 days in jail.

Healthcare fraud is a Class A misdemeanor if the crime led to the theft of more than $750 but less than $2500. Someone convicted of this type of misdemeanor can be sentenced up to one year in jail and have to pay a fine of up to $4000.

 A Texas state felony charge is reserved for healthcare fraud that results in the loss of more than $2500 but less than $30,000. It merits punishments like a prison term of up to two years and a fine of up to $10,000.

A person can be charged with a third degree felony if he or she commits healthcare fraud totaling more than $30,000 but less than $150,000. This charge applies if the person commits more than 25 but less than 50 healthcare fraud crimes. He or she can be sentenced to up to 10 years in prison and pay a fine of no more than $10,000.

A second degree felony results from the loss of more than $150,000 but less than $300,000 or if the person commits more than 50 incidences of healthcare fraud. The punishments for this felony conviction include a prison term of up to 20 years and a fine of up to $10,000.

Finally, people can face a first degree felony charge for healthcare fraud if they receive fraudulent payments or benefits that total more than $300,000. They can be sentenced to up to 99 years in jail and pay a fine of up to $10,000.

Schedule a free consultation with attorney Greg Tsioros »

How to Avoid Healthcare Fraud

Healthcare providers, patients, insurers, pharmacies and other medical organizations can avoid being charged with healthcare fraud by taking a few simple measures. The most basic tips to avoid committing this crime include:

• Never falsifying medical records
• Billing for only the medical services that were performed
• Never inflate the prices for services rendered
• Performing only medically necessary procedures

Likewise, they should avoid taking kickbacks for accepting patient referrals or performing procedures that insurers would not agree to pay for otherwise. 

Reasons to Hire an Experienced Attorney

If you find yourself charged with healthcare fraud in Texas, you need to hire an experienced healthcare fraud attorney to represent you. Your attorney can be crucial to proving your innocence and helping you avoid the most serious consequences with being found guilty of this crime.

Your attorney also understands how the state’s healthcare fraud laws work and how they apply to your case. Attorney Greg Tsioros can provide thorough, empathetic and professional representation to sway the court to find in your favor or avoid sentencing you to years in prison and ordering you to pay expensive civil fines.

Healthcare fraud in Texas can lead to serious repercussions that may land you in prison or paying fines that you cannot reasonably afford. However, you can take a number of simple steps to avoid this crime altogether. You can understand how Texas defines this crime and learn about the most common examples of it. You can also hire an experienced healthcare fraud attorney like Greg Tsioros to represent you.