Healthcare fraud (Article 180 of the Criminal Code of Georgia) is an economic crime often related to the misappropriation of funds from insurance companies or state programs (e.g., universal healthcare). This can manifest as registering fictitious patients, billing for procedures not performed, upcoding diagnoses to receive more funding, or writing off medications. Charges are brought against clinic managers, doctors, and accountants alike. Fraud in the healthcare sector is considered a crime of high public interest as it damages the budget and patient interests. Cases in this category require special knowledge of working with financial and medical documentation to distinguish technical errors from intentional fraud.
What does the Healthcare Fraud Defense service cover?
Lawyers specializing in white-collar crimes provide defense for clinics and medical personnel. Services include:
- Financial audit: Checking the clinic's billing and reporting system to determine if errors were systematic.
- Medical record analysis: Establishing correspondence between performed procedures and insurance claims. The lawyer proves that the treatment was actually performed and was necessary.
- Interaction with State Audit: Appealing acts from the Ministry of Health's monitoring service.
- Investigation of cooperation schemes: Refuting allegations of "kickbacks" between pharmaceutical companies and doctors.
Common Real-World Scenarios
Charges are often related to the following scenarios:
- Fictitious hospitalization: Registering a patient as an inpatient when they were actually treated at home, to receive funding.
- Writing off expensive drugs: Writing off oncological or other expensive medicines on paper and actually selling them on the "black market."
- Insurance fraud: Collusion between doctor and patient to perform a procedure (e.g., plastic surgery) not covered by insurance under the guise of another diagnosis (e.g., deviated septum).
- Service inflation: Prescribing unnecessary tests for a patient to increase the clinic's revenue.
Georgian Legal Framework
The main article is Article 180 of the Criminal Code of Georgia (Fraud). Articles on document forgery (362) or abuse of office (220, 332) may also be used. In the case of state programs, this is treated as misappropriation of state budget funds. The defense strategy is often based on proving that an administrative misconduct or billing error occurred, rather than an intentional crime.
Process and Stages
The defense strategy includes:
- Internal investigation: Establishing facts within the clinic and identifying responsible persons.
- Expertise: Conducting financial and computer expertise to check electronic databases.
- Negotiation with the state: Reaching a plea agreement in exchange for compensation of damages.
Why choose a specialist on Legal.ge?
Healthcare fraud is a complex category requiring knowledge of financial and medical fields. Legal.ge allows you to find lawyers specializing in white-collar crimes within the healthcare sector. They will protect your clinic and reputation. Find a defender on Legal.ge.
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