Doctor Medicare Fraud
Each year in the United States, 140 million people pay or owe taxes by the end of the fiscal year. Yet, in 2018, there were only 517 tax fraud convictions. Despite the incredibly low probability of being convicted of a tax crime, most Americans are still wary of incurring the wrath of the IRS.
At the same time, there are just over 1,000,000 doctors in the country, roughly 90 percent of whom accept Medicare. Incredibly, in 2018, there were more than 600 doctors charged with Medicare fraud, the vast majority of whom will, in some way, be convicted.
Put another way; there are probably fewer doctors in the entire country than there are severe tax evaders. This means that doctors are far more likely to be convicted of healthcare fraud than taxpayers are even to be investigated for tax evasion. Zealous law enforcement efforts also say that doctors are more likely to be convicted of work-related crimes than those in just about any other profession.
Don’t get caught in the dragnet
The reason for such disproportionate concentration on the healthcare sector by law enforcement is simple: Healthcare fraud in the United States is estimated to cost over $200 billion per year, seriously undermining our already-strained healthcare system.
But in their vigorous efforts to stamp out Medicare fraud, the various law enforcement agencies tasked with doing so have been notoriously prone to catching innocent bystanders in their all-consuming dragnets. And the consequences, both personally and professionally, of becoming the target of the law’s almost infinite investigative and prosecutorial resources, can be devastating.
The Healthcare Law Group has decades of experience in defending healthcare professionals against Medicare fraud charges. In most cases, we can successfully steer an investigation away from the criminal courts before our clients are facing prison time and crushing fines.
If you are a healthcare professional who believes you may be under investigation for healthcare fraud, getting ahold of the Healthcare Fraud Group as early as possible is the single best move you can make. From the first second that you come under suspicion, we use our deep expertise including the fact that many of our lawyers themselves have law enforcement backgrounds, to ensure that simple mistakes don’t turn a Zone Program Integrity Contractor audit, the dreaded ZPIC, or a civil investigative demand into a criminal case.
Cardiologists are increasingly becoming targets
One of the unfortunate consequences of giving various agencies a mandate to aggressively pursue any cases of possible healthcare fraud has been the creation of perverse incentives.
Auditors for the various divisions and contractors of the Centers for Medicare and Medicaid Services have been given a definite purpose: to recover as much money as possible. These auditors are rewarded, often through direct compensation, according to how well they perform the above task. Unsurprisingly, this has led to many highly questionable conclusions, usually to the detriment of healthcare professionals who find themselves under audit.
But not all medical practices in every field have been equally targeted. All medical practitioners working within cities that the Centers for Medicare and Medicaid Services have deemed to be high risk have a much-increased chance of being audited, investigated, and ultimately charged with healthcare fraud. These cities include Detroit, Houston, New Orleans, St. Louis, and others where there have been elevated numbers of healthcare-fraud cases.
But even more importantly, specific fields have been the target of invasive audits far more frequently than others. And these audits, the most infamous of which is the ZPIC, are the most common way that criminal investigations into individual doctors or their offices begin.
Among the fields that have been heavily focused on by auditors and investigators is cardiology. Whether true or not, cardiologist Medicare fraud is perceived by administrators and law enforcement to be a severe and growing problem. There are many high-profile cases where cardiologists have engaged in wantonly fraudulent behavior. Unfortunately, more often than not, the cardiologists that are targeted turn out to have made innocent mistakes or to have followed non-conforming practices without any criminal intent.
But without the early intervention of expert legal counsel, like the Healthcare Fraud Group, an audit that uncovers allegedly unauthorized billing to Medicare can quickly morph into a criminal investigation and eventual grand jury indictment.
Why cardiologists are targeted for hefty fines, restitution and even jail time
Cardiology is largely a preventive branch of medicine. A very high proportion of treatments, tests, prescriptions, and devices that cardiologists order are not strictly life-or-death matters. The simple reason is that when cardiac ailments are left untreated, the resulting problems, such as a myocardial infarction or malignant arrhythmia, often leave no second chances. Whereas a cancerous tumor of a particular grade will kill a patient within a year, a partially occluded coronary artery merely could kill them, or the patient could still be alive and symptom-free two decades later.
This is why so many cardiologists will order EKGs, echocardiograms, nuclear heart scans, Holter monitors, elective stent placements, and a host of other treatments even when the patient’s life may not be in immediate danger. Unfortunately, the elective nature of so many cardiology-related treatments gives aggressive and often-unscrupulous auditors and investigators nearly limitless opportunities to characterize treatments as being medically unnecessary. Without expert legal counsel to defend against such allegations, the chance of a doctor emerging unscathed is low.
ZPIC auditors and investigators are often highly motivated to generate fines and recoup supposed losses. This means that cardiologists are very frequently accused of exceeding medical necessity when recommending or ordering any of the following:
- Stress tests and EKGs.
- Opioid prescriptions.
- Cardiac catheterization or heart-tissue biopsies.
In cases where a patient’s life is not clearly at risk, nearly any cardiac treatment can be mischaracterized by an experienced investigator or auditor as medically unnecessary. And while the provision of allegedly medically unnecessary treatments is a leading reason for doctors to be both fined and criminally charged, there are many other reasons why auditors, investigators, and prosecutors may go after a healthcare professional. The most common factors leading to accusations of cardiologist Medicare fraud are:
- Accepting illegal kickbacks or patient referrals as proscribed by the Stark Laws.
- Billing Medicare for services that were not rendered or that were provided in a substandard way.
- Waiving patient copays while overbilling Medicare to make up the difference.
- Upcoding, which is billing for more expensive services than those that were actually provided.
- Unbundling, which is billing services separately that should all be billed as part of a single service.
- Falsifying a diagnosis.
It’s important to understand that Medicare-fraud cases do not follow the usual pattern of American law enforcement. Doctors who run successful practices, particularly if they are located in a high-risk city or practice in a targeted medical field, will be automatically flagged when their clinics produce outlier results. This, in turn, often leads to a full ZPIC audit, which can be difficult to tell apart from a criminal investigation.
ZPIC auditors are frequently aggressive and are quick to refer cases to law enforcement. Taken as a whole, this means that medical providers are often effectively subjected to precisely the kind of non-specific search, sometimes referred to as a fishing expedition, that the 4th Amendment bars. On top of this, under the False Claims Act, one of the most frequently used laws in cases of Medicare fraud, does not necessarily require criminal intent, only reckless disregard for established protocols and standards of care.
All this makes fighting Medicare fraud cases a challenging and highly particular field of legal practice. At the Healthcare Fraud Group, we bring decades of experience to bear on behalf of our clients, helping them navigate mine-laced ZPIC audits and avoid having simple mistakes turn into criminal charges.
Although they are not as frequently targeted as other medical specialties, oncologists and other cancer-related medical professionals can also become the focus of ZPIC audits as well as criminal Medicare-fraud investigations.
Cases of cancer Medicare fraud can bring penalties that are as stiff as any that have been handed down. And all doctors who practice a cancer-related specialty should be aware that their field may become the target of auditors and investigators at some point in the future.
The treatment of cancer often involves some of the most expensive drugs that exist as well as a wide range of treatment options that can include extremely expensive surgeries. This means that oncology and related fields fit the profile for the types of practices that ZPIC auditors love to target.
All medical professionals working in cancer-related fields should establish and closely follow proactive compliance programs. The Healthcare Fraud Group can help oncologists and related professionals design and implement such programs, a major step forward in keeping auditors away.
Cardiologist and oncologist Medicare-fraud penalties
Over the last decade, there have been a number of high-profile Medicare-fraud cases that have involved cancer specialists as well as cardiologists. The penalties handed down in these cases have been among the harshest ever, with some defendants being sentenced to effectively spend the remainder of their natural lives behind bars.
While such draconian punishments are typically only handed out in the most egregious cases of systematic abuse and fraud, hundreds of cancer specialists and cardiologists were handed lesser sentences over the same period, without making headlines. Even on the low end of the sentencing spectrum, many Medicare-fraud defendants end up serving multiple years behind bars, being ordered to pay crippling restitution and, ultimately, losing their medical licenses and their ability to work in their chosen profession.
On the high end, those who flagrantly violate the legal, ethical, and procedural standards of Medicare and the medical profession as a whole are often handed exemplary sentences meant as much to deter others as to punish the defendant in question. Notable cases where cardiologists and cancer specialists have been condemned to harsh fates include:
- A Detroit doctor that was sentenced to 45 years in federal prison. The 50-year-old doctor had systematically treated patients for diseases from which they did not suffer. He administered chemotherapy, often with irreversible long-term side effects, to many patients who turned out not to have cancer at all. He also engaged in an ongoing illegal kickback scheme. He was ordered to forfeit more than $17 million and will only be eligible for release when he is 84.
- A California oncologist was recently sentenced to 18 months in prison and to pay $1 million in restitution for billing Medicare for treatments that were never provided as well as upcoding treatments that were, in fact, administered.
- A New Jersey cardiologist was sentenced to 6.5 years in federal prison and ordered to pay nearly $20 million in restitution after having been found guilty of ordering medically unnecessary tests as well as fraudulently billing Medicare for services rendered by an unlicensed healthcare worker as if those services had been performed by a real doctor.
- An entire Texas oncology clinic was sued and ordered to pay more than $11.5 million for filing false claims and violating anti-kickback statutes.
- A Kansas cancer specialist is currently facing more than a decade in federal prison after having been convicted of falsely billing Medicare for more than $30 million after patients were apparently intentionally misdiagnosed.
In addition to lengthy prison sentences, huge fines, and crushing restitution, medical professionals that attract the attention of auditors or investigators may find themselves facing serious administrative and civil penalties as well. Oftentimes, these can be nearly as bad as being locked up, effectively ending careers and putting clinics out of business.
Serious administrative and civil penalties arising from a Medicare-fraud audit or investigation may include:
- A recommendation to the relevant medical board to suspend or revoke a practitioner’s license.
- The Centers for Medicare and Medicaid Services barring a medical office or doctor from participating in Medicare or Medicaid.
- Clawing back Medicare reimbursements that were found to have been improper or fraudulent.
- The imposition of large civil judgments against medical businesses and professionals.
The Healthcare Fraud Group will fight to win on your behalf
The fact is that while there are occasional cases of wanton Medicare fraud the vast majority of such cases involve simple errors that have been made by otherwise well-intentioned staff.
The Healthcare Fraud Group is comprised of lifelong professionals who know the Medicare program and the medical specialties that it encompasses inside and out. We bring our deep expertise to bear on our clients’ behalf, leveling the playing field when dealing with federal agents who have spent decades honing their ability to extract the maximum penalties from healthcare providers.
Something as simple as giving the wrong information on a form or telling an agent that a patient record doesn’t exist can turn a civil proceeding into a criminal one. The Healthcare Fraud Group will help you avoid those mistakes by coming in early and continuing to hit back hard when auditors or investigators overstep their bounds.
Because many of our lawyers once worked on the other side of the courtroom, we know the feds’ jobs often better than they do. And we use that knowledge to give our client the biggest possible edge, reaching satisfactory outcomes and avoiding criminal cases and jail the vast majority of the time. In fact, none of our clients has ever been sentenced to prison.
If you believe or know that you have become the target of a federal audit or investigation, contact the Healthcare Fraud Group today by calling 888-402-4054. The earlier we can start fighting on your side, the more likely it is that we can reach a conclusion from which you can walk away satisfied.