Healthcare Fraud Defense for Medical Professionals in New Hampshire: Protecting Your License
Healthcare fraud in New Hampshire can lead to federal prison and the loss of your medical license. The state aggressively prosecutes upcoding, phantom billing, and Anti-Kickback violations, often recovering millions in fines.
Practicing medicine in New Hampshire requires navigating an incredibly complex web of billing regulations. Whether you operate a dental clinic in Nashua, a pharmacy in Manchester, or a home healthcare agency in Concord, submitting claims to Medicare, Medicaid, or private insurers exposes you to intense government scrutiny. What might appear to be a simple administrative billing error can quickly escalate into a full-blown criminal investigation for healthcare fraud.
A conviction for healthcare fraud does not just threaten your financial stability; it threatens your freedom and your professional licensure. Government agencies have nearly unlimited resources to audit your practice and pursue severe penalties. If you are facing an audit or criminal charges, utilizing our directory to find a specialized white-collar defense attorney is vital. Below is an overview of the most common fraud allegations and how to protect your medical license.
Common Types of Healthcare Billing Fraud
Prosecutors focus on specific patterns of illegal billing. When the government suspects you are draining resources from federal or state healthcare programs, they often build their cases around these primary categories.
Upcoding and Unbundling
Upcoding occurs when a medical provider bills for a more expensive service or procedure than what was actually provided. For example, billing a routine 10-minute checkup as a highly complex 45-minute consultation. Unbundling involves billing separately for procedures that should legally be billed together under a single, cheaper code. Both practices violate the 31 U.S.C. § 3729 (Federal False Claims Act), leading to massive financial penalties.
Phantom Billing for Services Never Rendered
Phantom billing is outright theft. This happens when a doctor or clinic submits claims for medical services, tests, or equipment that the patient never received. Home healthcare agencies are frequently targeted for phantom billing, particularly when employees forge patient signatures to bill for daily nursing visits that never actually occurred.
Anti-Kickback Statute Violations
The federal 42 U.S.C. § 1320a-7b (Anti-Kickback Statute) makes it a criminal offense to knowingly offer, pay, solicit, or receive any remuneration to induce referrals for items or services covered by federal healthcare programs. For example, if a pharmaceutical company pays you disguised 'speaking fees' in exchange for prescribing their expensive medications, both you and the company can face severe federal prison sentences.
Billing for Medically Unnecessary Procedures
The government will not pay for treatments that a patient does not genuinely need. If a dentist performs and bills for unnecessary root canals, or a doctor orders expensive and repetitive MRI scans solely to boost clinic revenue, they are engaging in fraud. Defending these charges often requires hiring independent medical experts to validate the clinical necessity of your decisions.
The Role of the NH Medicaid Fraud Control Unit (MFCU)
In New Hampshire, state-level investigations are heavily driven by the New Hampshire Medicaid Fraud Control Unit, Concord. Operating under N.H. Rev. Stat. Ann. § 167:61-a, the MFCU is specifically tasked with investigating and prosecuting providers who defraud the state's Medicaid program. The MFCU routinely performs unannounced audits and relies heavily on tips from whistleblowers (often disgruntled former employees) who can receive a percentage of the recovered funds. Precedents like State v. Hermsdorf, 135 N.H. 360 (NH Supreme Court 1992) demonstrate the state's rigid stance on Medicaid compliance.
Collateral Consequences for Your Professional License
The criminal penalties for healthcare fraud are severe, but the collateral consequences are often career-ending. If you are convicted, or sometimes even just indicted, you face immediate disciplinary action from your state licensing board.
| Profession | Governing Body | Potential Disciplinary Action |
|---|---|---|
| Physician / Surgeon | New Hampshire Board of Medicine, Concord | License suspension, revocation, and exclusion from Medicare/Medicaid. |
| Dentist | New Hampshire Board of Dental Examiners, Concord | License revocation, massive administrative fines. |
| Pharmacist | New Hampshire Board of Pharmacy, Concord | Loss of pharmacy license, DEA registration revoked. |
To fight an administrative suspension, your lawyer must file a written request for an adjudicative hearing pursuant to N.H. Code Admin. R. Med 206, presenting a robust defense before the licensing board strips you of your livelihood.
Frequently Asked Questions (FAQ)
What is the difference between an error and fraud?
The core difference is intent. A genuine administrative mistake or a misunderstanding of complex coding rules does not constitute criminal fraud. The government must prove you knowingly and willfully intended to deceive the billing program.
What is Medicare exclusion?
If you are convicted of healthcare fraud, the Office of Inspector General (OIG) will place you on the Exclusion List. This legally bans you from participating in or billing any federal healthcare program, effectively ending most medical careers.
Can my clinic be held liable for the actions of a single rogue employee?
Yes. Under the False Claims Act, a healthcare practice can be held financially liable for the fraudulent billing practices of its employees if the owners failed to implement adequate compliance and oversight protocols.
Should I conduct an internal audit if I suspect a problem?
Yes, but it must be done carefully. You should hire an attorney to conduct the internal audit so that the findings are protected by attorney-client privilege. If errors are found, your lawyer can help you self-report to minimize penalties.
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