A Conspiracy To Commit Healthcare Fraud Or A Mistake?

Defending Yourself Against A Healthcare Fraud Investigation

There’s supposed to be a very clear distinction between fraud and a mistake. That distinction lies with knowledge and intent. For example:

You’re running a small medical practice and have just hired a new billing specialist. This new employee is unfamiliar with your system and has skipped the training. A few weeks into their employment, you discover they’ve been submitting duplicate claims to a number of patients’ health insurance companies.

  • Mistake: The new billing specialist didn’t know they were submitting duplicate claims. They understand and accept that they’ve made a mistake and work with you to correct the errors.
  • Fraud: The billing specialist knew they were submitting duplicate claims. They tried to hide it from you and other office personnel. They’ve also managed to pocket the extra money paid out from the insurance companies.

Here’s where things get tricky. If you don’t report the incident, you’re likely to become part of an investigation. If you’re indicted and convicted, you’ll have to bear the brunt of a healthcare fraud penalty. If you report the incident, there’s still a chance you’ll become a target in the investigation anyway.

How Do You Know You’re Under Investigation For Committing Healthcare Fraud?

The fact is that there aren’t any hard and fast ways to know you’re being investigated unless the presiding agency makes it known to you. Here are a few ways you can be notified of a pending or ongoing investigation:

  • Unfortunately, many people find out that they’re being investigated once they’re served with search warrants for their homes, offices, and seizure of their personal and professional property.
  • A target letter can be sent from federal prosecutors letting the person know that they’re under investigation. It also gives them the opportunity to cooperate with the case.
  • You can receive a subpoena to produce documentation in relation to a pending case.
  • You may be approached by officials asking you to provide affidavits or witness testimony for their investigation. They may act nonchalant and allow you to believe that divulging incriminating information won’t land you in hot water, or worse, as the target of the investigation yourself.

Facing Healthcare Fraud? Act Now!

If you are a healthcare provider there are important federal fraud and abuse laws that you should be aware of and comply with:

  • False Claims Act (FCA) – This is pretty straightforward. Avoid overcharging the government by submitting false claims to Medicaid or Medicare. The violator doesn’t have to have specific knowledge of the fraudulent claims; willful ignorance of the fraud is enough to violate the law. The criminal penalties for submitting false claims include imprisonment and criminal fines, while the civil penalties include damages up to three times the amount of the loss from the entity, plus an additional $11,000 per false claim filed.
  • The Anti-Kickback Statute (AKS) – While other industries reward you for referring business, it is illegal in the federal healthcare realm. Receiving or referring patients that results in the knowing generation of business, or anything payable from the government, is illegal. Furthermore, rewards don’t have to be monetary. They can come in a number of forms such as free rent, excessive compensation from consultation fees, or expensive meals or hotel stays. Penalties include being excluded from federal programs, along with fines, jail time, and paying up to three times the amount of the reward in fees.
  • The Physician Self-Referral Law (Stark Law) – As a physician, you cannot refer patients to another provider with whom you, or someone you are immediately related to, have a financial interest in, unless an exception applies. Penalties include hefty fines and removal from further participation in federal programs.
  • The Exclusion Authorities and the Civil Monetary Penalties Law (CMPL) – If an individual has been previously convicted of specific felony charges relating to Medicare and Medicaid fraud, healthcare fraud, or financial misconduct, they are not allowed to participate in federal healthcare programs. This will more than likely result in not being reimbursed from federal healthcare programs if you’re found to be an excluded individual.

More information on these laws can be found here on the site for the Office of the Inspector General: US Department of Health and Human Services.

Not all healthcare fraud cases involve medical practices or personnel, so don’t be surprised if you’re facing a pending case despite not being in the medical industry. Fraud can happen at any type of business, or perpetrated by any individual. Some examples include:

  • Forging or altering healthcare bills to acquire reimbursements.
  • Using someone else’s insurance card, or allowing someone else to use yours.
  • Filing false or duplicate claims for procedures you didn’t receive.
  • Filling a prescription under your insurance and selling it to net a profit.
  • Forging and selling prescription medications or the prescriptions themselves.
  • Misrepresenting symptoms and services to get covered when they’re actually not covered by your policy.
  • Conspiring with your healthcare provider to commit fraudulent acts like duplicate billing, giving the wrong diagnoses in order to perform extra and unnecessary procedures, and waiving your co-pay in order to overbill the insurance company.

Accept The Depth And Seriousness Of A Healthcare Fraud Investigation

The last thing anyone should do is understate the severity of a pending federal case. There are many instances where people wait too long to retain counsel and as a result, face the harshest penalties due to their decision not to take the investigation seriously. Once you’re sure that you’re being subpoenaed or targeted, there are a few things that you should keep in mind.


As much as you may enjoy posting updates about your life and how you’re being treated unjustly, your best bet is to exercise your right to remain silent. Keep posts about any pending charges, investigations, and trials to yourself and outside of the public viewing. Keep in mind that anything you decide to post can be used against you. Also, social perception doesn’t always work in your favor. Tarnishing your public image or professional reputation by the mere association with a federal trial will take more time to undo than it’s worth. Therefore, it is recommended that you just keep the information to yourself.

Don’t Talk To Anyone Without Your Attorney

As intimidating as it may be, you shouldn’t speak to any federal agencies or personnel without your attorney present. Don’t volunteer information. You don’t have to be combative, but make sure that they know you’re willing to cooperate so long as you can consult your legal counsel prior to doing so. Any type of paperwork you receive, from letters to subpoenas, should be reviewed by your attorney. They’ll be able to explain everything expected of you from the notices you receive.

Help Your Attorney Help You

Once you’re aware of a pending trial, it helps to gather as much information as possible to help your attorney help you. A good healthcare fraud defense attorney will be able to help you assess whether the matter is criminal or civil, along with the severity of the charges and how to proceed. They’ll also be able to help you navigate the specifics of which laws you’re being accused of violating. You should work with your legal team to prepare your defense as soon as possible. Whichever federal authority is overseeing the investigation will have time on their side, as they’ve probably been looking into you and your life for a while prior to informing you that you’re under investigation.

Avoid These Common Mistakes

DO NOT DESTROY EVIDENCE! – The first thing people want to do when under pressure of a court proceeding is to get rid of anything that may look incriminating. Don’t make that kind of mistake, especially under duress. The prosecutors won’t see it as a mistake and will more than likely add charges to the case they’re building against you. Consult your legal team if you find anything that you suspect may be incriminating or questionable.

Don’t talk about your case to friends, family, or co-workers. Any kind of communication, from emails and text messages to online messages and social media posts, can all be subpoenaed and used against you. People who you speak to may find themselves forced to testify to things they saw and heard you say in regards to the investigation. No one wants to be part of a commit health care fraud charge.

Healthcare Fraud Defense Isn’t a Do-It-Yourself Endeavor

Professionally licensed legal counsel is always the best option when facing healthcare fraud charges. It doesn’t matter if you’re guilty, innocent, or somewhere in limbo; navigating the legal waters of any pending indictment is best done by a team well experienced in handling healthcare fraud cases. Here are a few instances where the Healthcare Fraud Group has shown their grit and worth when it comes to putting their clients’ needs and defense first:

  • The Healthcare Fraud Group was responsible for the defense in the largest verdict in the United States in 2017, and the ninth largest verdict in United States history against JPMorgan Chase Bank for an amount in excess of $6 billion for malice, fraud, breach of fiduciary duty, conversion, and gross negligence.
  • The attorneys of Bell P.C. have served as lead counsel for a pharmaceutical company against TWINMED during arbitration in a $10 million defense case and won the case for the defendant!
  • Bell P.C. attorneys have served as lead trial counsel for a medical provider client and obtained a substantial jury verdict, in addition to securing party attorney’s fees from the Hospital.
  • The Healthcare Fraud Group was able to secure a $50 million settlement for a client arising from a confidential dispute.
  • Successfully obtained a dismissal for clients while serving as lead counsel in a Qui Tam healthcare lawsuit.
  • Successfully defended a client in a fraud investigation by the U.S. Attorney’s Office and the FBI. The case resulted in no civil or criminal liability.

With results like these, our team is ready to go to work for you. If you’re facing a pending investigation, let’s work together to get you the best results possible.

If your health care business, practice, small business, corporation, or organization is currently under any kind of investigation, please call the Healthcare Fraud Group. You can schedule an initial consultation with a knowledgeable healthcare fraud defense attorney. Our team can review your case immediately and get started on preparing an adequate defense. We can even help you create a compliance program or craft a plea deal to minimize the costs of time and expenses.

We have over 100 years of combined experience in defending clients against charges that can result in imprisonment, significant monetary fines, and reputation damage that can take years to recover from. Call the Healthcare Fraud Group today at 855-337-6836 or contact us online to schedule your confidential consultation.

“When companies, careers, and reputations are riding on the results, we will go all the way.”

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