Health Care Fraud Defense
When Everything Is On The Line - You Need The Best
If you or your company have been accused of health care fraud or abuse, it is essential to have an experienced and knowledgeable attorney by your side to help you navigate the complex legal system and strict deadlines. Our firm assists individuals working in the health care industry, including physicians, pharmacists, and chiropractors who are experiencing a federal audit or investigation.
The process of an audit or investigation can be a very stressful time for you and your employees. It can also be disruptive for your business. The consequences of unfavorable findings can be severe and have long-lasting effects. The government’s inquiry could threaten both the company and the livelihood of the owners and practitioners.
Our professional team of health care fraud defense lawyers is knowledgeable, experienced, and ready to work diligently to defend you in this difficult time. We aim to provide aggressive representation. Our years of experience can provide the best possible defense and, in many instances, we may be able to get the charges dismissed altogether. It is essential to act rapidly if allegations have been made against you. Failing to defend yourself promptly and adequately could have severe consequences such as civil or criminal penalties.
Types of Health Care Fraud
There are many common types of health care fraud and abuse. When a company or an individual makes a false statement or statements against your company and engages in illegal practices for financial gain, this is considered healthcare fraud. Healthcare professionals often find themselves unexpectedly facing fraud charges. This may be due to the actions of an individual employee, a physician, or a pharmacist being accused of misconduct.
Health care fraud has become so common that federal and state agencies are working hard to mitigate the problem. Common allegations made against healthcare professionals include billing fraud, fraud involving Medicaid and Medicare schemes, Anti-kickback violations, and False Claims Act Violations.
Whatever situation your health care practice is facing, our defense lawyers will gather all pertinent evidence, documents, and information needed to have a successful outcome. Many government organizations such as the Department of Justice (DOJ), Centers for Medicare and Medicaid Services (CMS), Drug Enforcement Administration (DEA), Office of Inspector General (OIG), and the Department of Health and Human Services (DHHS) may conduct investigations and make allegations against your business. In more serious cases, you may be investigated by agencies such as the Federal Bureau of Investigation (FBI) and the Internal Revenue Service (IRS).
Health Care Fraud Investigations
It is common for physicians and healthcare entrepreneurs throughout America to proactively hire health care fraud lawyers. We can prepare defenses against any allegations that have been made during a state or federal investigation.
We have a team of experienced healthcare fraud defense lawyers with a reputation for excellence, who have advised hundreds of clients on complex legal matters. Engage our health care attorneys to represent you. We work expeditiously to settle the government’s investigation. In many cases, we can resolve the situation before proceeding with litigation. Our team can provide you with a free and confidential assessment of your needs. We can then evaluate why you are being audited or investigated. We can also research the possible consequences and penalties that may be assessed
Health Fraud Examples
We have helped clients who have found themselves in many different types of health care fraud and abuse cases. These include clients who are accused of overbilling on Medicaid, Medicare, Tricare, or DOL. We have also assisted those who have been investigated for using reimbursed funds from Medicare to pay referral fees or kickbacks.
Other clients have been accused of creating phantom bills – billing for treatments, or services that weren’t received or weren’t medically necessary. We have also worked on cases where health care providers have been accused of double-billing either a private health insurer or a federal benefit program. Coding violations such as upcoding and unbundling have also been an issue.
Falsifying patient records:
Practitioners may be accused of falsifying patient records or providing fake test results to charge for a treatment that the patient does not require.
Prescribing and dispensing medication:
We have also defended pharmacists who have been accused of improper conduct while prescribing, dispensing, and billing for drugs, especially opioids. Our experienced attorneys have worked on cases involving regulatory authorities and agencies. We have managed to avoid prosecution under federal law and have won trials in cases involving health care fraud allegations.Another example of a health fraud case we worked on recently was the improper use of physician certifications and patient election statements.
Medical laboratory testing fraud:
A typical health care fraud scheme involves the medical laboratory industry and revolves around medically unnecessary ordering of tests. Clinical laboratories can run unnecessary tests that are excessive or inappropriate for a patient’s diagnosis. This adds a significant financial burden to the health care insurance benefits and can also put patient’s lives in danger.
Health Care Fraud and the Opioid Epidemic
In America, we often hear about the opioid epidemic and its shocking number of deaths that are unnecessarily caused by overdoses. The government spends large amounts of money annually to combat the problem. The public does not often hear about the role health care professionals play in contributing to the opioid epidemic through fraud and illegal practices.
In many opioid cases, health care fraud has taken place as a result of patient conduct. Patients committing fraud by falsely reporting an injury or making false claims to obtain medications that they don’t necessarily require. In other cases, it may be the medical practitioner who’s at fault if they don’t follow the strict laws regarding opioids when disbursing prescription drugs.
Work with Our Health Care Fraud Attorneys
We follow strict guidelines when you hire professional help from our health care fraud attorneys. These guidelines ensure that you receive the support required to resolve your case.
We will start work on your case immediately evaluating your case, gathering evidence, and obtaining relevant information and documentation. We have a proven record of working on health care fraud and abuse cases. Our wealth of knowledge in this area allows us to understand the medical and legal issues you are facing and provide legitimate options for proceeding.
Unproven allegations can have a devastating effect on your business, which is why we work diligently to resolve your case. We will first assess your situation, research the allegations, and determine if they are civil or criminal charges.
It is best to be prepared for all eventualities knowing that having federal charges pressed against you is a real possibility. However, it’s possible to resolve your case before a trial is necessary. Our firm of qualified health care fraud attorneys has resolved many of our client’s cases at the investigation stage. Therefore, completely avoiding litigation.
If your case gets taken to court, we will be prepared to defend your business with persuasive arguments and substantial evidence proving your case. We will also provide information to you every step of the way, so you understand the process, what is coming next, and your options for proceeding.
Throughout each step of the process, we will also be there to support you and your employees. We will advise on any decisions that need to be made whether they are small decisions or large ones. There are many common mistakes that need to be avoided when you have accusations pending against you or your business. Your staff will also be advised on how to properly respond to anyone asking them questions about the accusations or business.
The Stages of Federal Health Care Fraud Prosecution
If you have been contacted by federal agents or auditors working with CMS If so, it’s crucial to find legal representation promptly as this will increase your odds of a successful outcome. There are strict timelines and guidelines which need to be followed when dealing with a federal case. The following are the stages of the Federal Health Care Fraud Prosecution:
1. Fee-For-Service Contractor Audits: If you are a Medicare-participating health care provider, then you will be subject to regular checks by a fee-for-service contractor. They will ensure that you’re complying with Medicare’s billing regulations. These auditors are specifically looking for violations as they receive financial incentives to find fraudulent Medicare billings.
If you are accused of violating Medicare’s billing procedures, we can represent you in your case audits and appeals. Agencies such as Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs) may be involved in the case. We have proven strategies to defend against unfavorable auditors and providers. One of our defense strategies is to challenge the auditors’ methods and discredit their allegations.
2. Health care fraud investigations: There are two different types of federal health care fraud investigations -civil and criminal. Both of these types of investigations can involve several different agents; therefore, each case is unique. Agencies such as CMS, routinely carry out investigations against health care providers. They look into physician-owned entities, telemedicine providers, and medical facilities, as well as medical equipment manufacturers.
Our lawyers aim to defend and represent clients from the time the allegations are presented, thus protecting them against civil or criminal liability. It is essential to get competent legal representation if you’re being targeted in a federal investigation in order to attempt to avoid prosecution.
3. Grand Jury Indictment: If you have been served with a grand jury indictment, you have been charged with a significant crime. It is in your best interest to act expeditiously in obtaining legal representation to limit damages to your company and professional reputation.
It is common for federal prosecutors to pursue criminal charges. Any past indictment on your part will be likely to result in a court case or trial.
Our team of experienced lawyers are able to represent clients in federal grand jury proceedings. We will work diligently to challenge subpoenas and false accusations while providing ongoing information and advice so you understand the process.
4. Defense Strategies: After you have received your indictment or a civil charge, it may take months for your case to receive a court date. This gives us a sufficient amount of time to research the allegations and prepare your case. Your case will go one of two ways – settlement or litigation. We will prepare you and your case for both situations. There are many different defense tactics we can use, depending on your situation.
Unlike many lawyers, we will try to resolve your case before it goes to court. Our experienced firm utilizes a variety of pre-trial defense strategies to help resolve your case prior to court such as negotiating plea deals and attempting to have indictments dismissed.
Our firm has successfully protected our clients’ businesses and prevented our clients from being sentenced to prison.
5. What Happens During Sentencing: If you are being tried at the federal level, there will be two separate proceedings – trial and sentencing. We must uniquely approach each of these, which our lawyers are experienced and well-versed in handling. We will draw on past experiences and proven techniques to protect you and your business.
At trial, if the government has not met its burden of proof, our job is to ensure the jury is aware of the lack of proof. If you are found guilty of any of your charges, we will refer to the Federal Sentencing Guidelines to ensure you are justly sentenced. It may be necessary to argue for a lower sentence if we feel you have been unfairly sentenced.
6. Appeals: Once your case has been tried and a sentence handed down, we are able to represent clients on appeal. If you feel that you were unfairly tried, our defense team will appeal on your behalf. We employ licensed professional appellate attorneys who can handle appeals in multiple U.S. Circuit Courts.
If you decide to file an appeal, you must act quickly, as there are strict timelines for filing an appeal. Missing the deadline may result in the inability to file an appeal and your company’s unjust outcome will stand unchallenged.
If you have been subject to consequences such as recoupments, denial of payments, or a pre-payment review due to your RAC or ZPIC audit, then you can file a request for redetermination. This would be carried out by a Medicare Audit Contractor (MAC).
If, after reviewing your audit findings, the MAC confirms that they are accurate, there are four other areas that you could appeal. These vary in severity and culminate with a filing in federal district court. We have experienced defense lawyers who have worked with all levels of the audit appeal process. We can represent clients in both civil and criminal health care fraud appeals.
An appeal will be very different from what you went through at the trial level. To achieve a successful appeal, you must employ an attorney with an in-depth knowledge of federal law and procedure. We can present a strong argument to help overturn your previous verdict.
Laws Used to Prosecute Cases of Suspected Health Care Fraud
There are many laws that agencies such as CMS, the OIG, and the FBI use to take action against health care practices. Four laws are most commonly used to take action. These are The Anti-Kickback Statute, the False Claims Act, the Stark Law, and the Criminal Health Care Fraud Statute.
This law makes it illegal to swap any goods or services for business opportunities under insurance providers such as Medicare, Tricare, and Medicaid. The Anti-Kickback Statute applies to all health care providers who use these programs. It’s relatively common for physicians to be caught abusing this statute and receiving unexpected investigations for illegally referring patients. In the case of the Anti-Kickback Statute, the definition of a “referral” is broader than most providers realize.
The False Claims Act
The False Claims Act was created to guard against false or fraudulent claims submitted under health care benefit programs such as Medicare. This type of investigation can lead to civil or criminal charges being brought against the health care provider or practitioner. You may be subject to an inquiry under the false claims act due to direct government investigation or because your business has had a referral from elsewhere. You could have been referred by a former employee, patient, or competitor who has received compensation in exchange for information about your business.Health care professionals can be held liable for submitting a false claim, either intentionally or by accident. However, to be considered a false claim and, therefore, health care fraud, you must have made the claim with the full intention of defrauding the government. If you or your employee have been negligent or made innocent errors, this is not enough to hold you liable for the fraudulent act.
The Stark Law
The third law which is often used to prosecute health care professionals is the Stark Law. This is a federal law that applies to physician referrals. This law prohibits “self-referrals” between doctors and other health care providers and stops providers from billing Medicare for referred services.The Stark Law was applied initially to physicians and their relationship with the labs. Nowadays, it applies to all health care agencies. Federal prosecutors commonly use the Stark law in cases against pharmacists, therapists, and other health care providers.
Criminal Health Care Fraud Statute
This statute states that it is illegal for health care practitioners to defraud a health care benefit program, such as Medicare or Medicaid, or to knowingly make false claims to obtain money from a health care program.
Consequences of Health Care Fraud
There are many consequences for health care providers, practitioners, and employees who have been involved in or accused of health care fraud or abuse. These range in severity from a civil or criminal fine, or recoupment to reimburse the government for any over billed Medicare amounts. You may also be charged with treble damages. If you are found to be guilty of health care fraud or abuse, you may need to pay the government’s legal fees.
Apart from financial loss, there may be other implications to your business or practice. You may be excluded from insurance companies such as Medicare, Medicaid, Tricare, and DOL. In cases where over billing has occurred, it’s common that businesses are subjected to ongoing pre-payment checks moving forward. You may also receive disciplinary action by state regulatory boards or loss of DEA registration.
Worst case scenario, practitioners, pharmacists, and medical practitioners could lose their medical license, pay exorbitant fees, or be imprisoned for years or even decades.
The federal prosecutor determines if a case is classed as criminal or civil, depending on the seriousness of the crime. If you have been accused of health care fraud, find out as soon as possible whether you are likely to be faced with criminal or civil charges. The U.S. Attorney’s office will often not reveal whether someone is facing civil or criminal charges until they have completed their investigations.
They may be investigating someone for a suspected civil violation. For example, they may be investigating a breach of the False Claims Act only to find that the case also involves criminal penalties. If the investigation involves the IRS, grand jury subpoenas, or the seizure of property, then it is likely that criminal charges will apply.
Contact The Healthcare Fraud Group About Your Case
Our attorneys work as part of a team to ensure we utilize our combined experience to better serve our clients. Our clients will receive intelligent advice and professional help while they are enduring a federal health care trial.
We can offer you a free fraud defense assessment and work with you to resolve your case. If you are a health care practitioner who is facing allegations of fraud or abuse, don’t hesitate, contact our health care criminal lawyers today. The government may already have built up a case for criminal charges, which we will work hard to counteract.
Our firm offers competent and confidential advice. Contact us today to talk to a health care fraud defense attorneys about the allegations that have been made against you or your business. Give us a call today at 888-402-4054.