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Self-referral and anti-kickback rules

On Behalf of | May 9, 2023 | Criminal Defense

Medicare and Medicaid provide government-sponsored healthcare coverage to older persons with limited financial means. Medicare and Medicaid issue millions of dollars in payments to physicians in Texas and other states, and some transactions involve fraud. Federal regulations attempt to curtail fraud, but incidents still occur.

Applicable laws

Under the Physician Self-Referral Law, a physician may not refer patients receiving certain health services Medicare or Medicaid pays to any party in which the physician or immediate family member has a financial stake. Exceptions apply in some instances. So, a doctor could find him or herself in legal trouble if they referred a patient to a rehab center owned by their spouse.

Self-referral laws involve physicians, which are not the same as anti-kickback regulations. Anti-kickback laws center on misconduct by anyone who knowingly and willfully seeks an unlawful benefit from an entity to receive payments from Medicare and Medicaid.

Defending against self-referral and kickback claims

As with other white-collar crimes, anyone charged with Medicare or Medicaid-related fraud or bribery can present a criminal defense. Sometimes, prosecutors paint an incorrect picture, and innocent persons may face federal charges. The above-mentioned statute notes that someone must knowingly and willfully seek a bribe, kickback or other benefit. The case might fall apart if the prosecution cannot prove both of these elements beyond a reasonable doubt.

Other issues may arise during the criminal defense process. If the investigators violated the defendant’s rights, evidence might become suppressed. Such could be when law enforcement fails to procure a proper warrant.

When the case against a defendant appears strong, a plea bargain may be worth pursuing. A plea deal might result in a lesser punishment than what the defendant may receive if found guilty at trial.