Healthcare fraud is big business in the US. As a result, the government has been keeping a close eye on providers and insurance companies. However, not every accusation is legitimate. Regardless of the validity of an investigation, the accused should never have to face the issue alone. The federal government has a plethora of resources available with which they go to great lengths to land convictions. This is why defendants all across the states need a healthcare fraud defense lawyer in their corner who is familiar with the government’s processes and can use that knowledge to establish a solid defense.

Having an experienced and knowledgeable legal advocate can make a significant difference in the outcome of a case. Even when there is merit to the accusations, the key is to use facts to achieve the best possible outcome. Many times the consequences outweigh the crime, which is why legal assistance is required to ensure that maximum penalties aren’t administered for something that doesn’t warrant them. It’s the job of a defense attorney to ensure that the outcome is fair.

If you suspect healthcare fraud in your workplace or are the subject of an accusation, there are certain things that can happen. First, you have the option to become a whistleblower and disclose the fraud. Or, you could find yourself accused of the fraud, in which case having a federal defense attorney by your side would be your best course of action. These scenarios are discussed in more detail below.

Common Types of Healthcare Fraud

There are 10 primary kinds of healthcare fraud. They are:

• Billing for services not delivered
• Billing a non-covered service as covered
• Changing the dates of service
• Billing for the wrong location than where services were rendered
• Billing for a provider other than the one that delivered the service
• Bribery and kickbacks
• Unnecessary prescriptions
• Overutilization of services
• Incorrect reporting of diagnoses or procedures
• Waiving copayments and deductibles

Each type of healthcare fraud is self-explanatory. Billing departments and providers are held to high standards in order to ensure that patients are billed correctly. Incorrect billing not only affects the patient, but it also affects the insurance company and the healthcare facility. The issues that arise can be very problematic and expensive for all involved parties. For instance, the insurance company could refuse coverage for a service that was provided but not billed correctly. That leaves the patient responsible for the cost of their care when they would not have been otherwise. If Medicare or Medicaid are involved, the matter becomes even more complicated because the federal government is affected directly.

An insurance company not paying a bill because it was billed incorrectly is what occurs when the insurance company catches the fraud. There are other times when they don’t catch it and they pay for something they shouldn’t have paid for. The provider on the receiving end of that payment benefits, but the insurance company takes a loss. When the fraud is later identified, the provider can be charged with healthcare fraud and required to pay fines, restitution, and other penalties.

Becoming a Whistleblower

If you are aware of healthcare fraud happening in your workplace, there are a number of things that you need to do. Those things are:

Be Confident in Your Allegations

If you are sure that you have seen healthcare fraud occur in your workplace, document everything. It’s possible that the person committing the fraud will do everything possible to cover their tracks. They may hide or delete communications and destroy documents. It is also common for the person responsible for the fraud to blame other people in order to spread the blame across the organization. This is another reason why it’s imperative to record everything. Then, take what you have recorded to your attorney. It’s important to make sure that what you have seen is, in fact, healthcare fraud. An experienced attorney can clarify the actions that you have witnessed and advise you on what to do next.

Be as Detailed as Possible

When recording your observations, it is important to be as detailed as possible. Document how and why you discovered the fraud, conversations about the fraud, and everything that happened after the discovery and/or any conversations. This information will be important for your lawyer to review and may be shown to the government in order to support the allegations. It is imperative that you share all observations, even if it may be uncomfortable to do so.

Communicate the Fraud to People in Charge

If the fraud is limited to one or several employees, it’s important to report it to your supervisor, HR manager, or another person in charge. Even if they ignore your disclosure, you can record that you reported the fraud to the individuals in charge. This will be important in a legal case, especially if you are accused of any wrongdoing.

Unfortunately, there are times when the individuals in charge don’t want to take any action out of fear that it will draw unwanted attention to the organization. Other times, it’s because some kind of kickback is being received and they don’t want to sacrifice those earnings. Healthcare fraud is a very lucrative business, which is why it’s so common and why there are healthcare providers that use it to pad their pockets.

If you know for a fact that there isn’t a single person in charge, compliance officer, or HR manager to report the fraud to, consider resigning your position. When the fraud is occurring company-wide, this can be the only way to make a report without retaliation or accusations.

It’s also possible that your position within the company can subject you to liability in the fraud case. If the government shows that you knew or should have known about the fraudulent acts being committed, you could be charged with healthcare fraud. For example; submitting bills to Medicare or Medicaid on behalf of the practice or facility could subject you to a charge of fraudulent billing, even if you were unaware that the claims being filed were false.

If you feel that you could be held liable in a healthcare fraud case but know that fraud has occurred, reporting it could work in your favor. However, consult with your attorney so that you are protected in every way possible, and take the proper steps toward disclosing the fraud.

Talk to an Attorney as Soon as Possible

Talking to your healthcare fraud defense lawyer as soon as possible is one of the most important things you can do for yourself and anyone else affected by the fraud. At Bell P.C., also known as Healthcare Fraud Group, we will provide you with the advice that you need to navigate your case. Whether you need advice on what to do next as a whistleblower, or you need to defend yourself against a healthcare fraud claim, we can help you.

We have established an incredible track record of success over the course of our firm’s existence. One of our most successful verdicts was achieved in 2017 against Chase Bank when they were required to pay $6 billion in damages for malice. This was the ninth-largest verdict in U.S. history.

We also served as lead counsel for a pharmaceutical company against TWINMED in a $10 million defense case that we won. Additionally, we served as lead counsel for a medical center that obtained a substantial jury verdict. In another case, a client in a confidential dispute landed a $50 million settlement with our help.

While we are successful in obtaining positive verdicts for our clients, we have also obtained noteable dismissals in Qui Tam healthcare lawsuits. In a case brought against a company by the FBI and the U.S. Attorney’s Office, our client was found to not be civilly or criminally liable.

Qui Tam Lawsuits

What exactly is a Qui Tam lawsuit?

When you are an employee that has discovered healthcare fraud happening within your organization by another individual, you can use the False Claims Act to file a Qi Tam suit against the alleged perpetrator. If the government recovers funds, the person who filed the lawsuit is entitled to a portion of the amount recovered.

When a Qui Tam lawsuit is filed, it is private. This means that there is no public disclosure of the lawsuit. It can take years for this type of case to be resolved, but employees are able to take a stand against healthcare fraud. The benefit of receiving a portion of the recovered funds is simply an incentive to get people to speak out. Speaking out can protect yourself and others from future fraud fallout.

What Companies Can Do to Stop Healthcare Fraud

It’s important for companies to fight healthcare fraud allegations because fraud convictions raises insurance premiums, cut benefits, and increases co-pays and deductibles. One of the best ways for a healthcare provider to combat fraud is to not participate in kickbacks, educate employees on how to spot fraud and abuse, and let employees know how they will be impacted.

Healthcare Fraud Defense

There are several defenses that are available. Which defense we use depends on the facts of the case. We understand that people make mistakes. If this is the case, than a defense can be built upon the fact that an honest mistake was made. An act must be intentional in order for it to be classified as fraud. If it can’t be proven that the act was intentional, a person can’t be convicted of fraudulent actions.

An example of a mistake that can be misconstrued as fraud is when a healthcare provider or insurance company accidentally bills improperly or accidentally omits information.

Lack of evidence is another defense used in healthcare fraud cases. If the facts don’t prove that healthcare fraud took place, a case can’t be made against the accused.

The Investigation Process

When healthcare fraud has occurred in the workplace, investigators will be appointed to look into what occurred. Information will be collected from providers, patients, and the insurance company, and then reviewed by the investigation team.

Investigators may also perform asset searches and surveillance in order to gather as much information as possible. If the investigator determines that fraud took place, the appropriate law enforcement agency will be given the evidence. The prosecutor then will bring the case against the accused if he or she feels that there is enough evidence to substantiate the accusations. Nonetheless, a prosecutor thinking they have enough evidence doesn’t always mean that they do; that is why insufficient evidence is another effective defense.

Speak with Our Healthcare Fraud Defense Lawyers Today

If you are or are considering becoming a whistleblower and you need an attorney to guide you through the process, the Healthcare Fraud Group can help you. It is important to protect yourself from any accusations and potential retaliation. Having the right legal guidance will help ensure this.

If your healthcare business, organization, or practice is being investigated, knowing what to do next without affecting the outcome of your case is where we come in. By scheduling an initial consultation with a skilled healthcare fraud defense attorney, you will find that we are knowledgeable and ready to take on your case. Our attorneys are ready to immediately start preparing an aggressive defense or help you create a compliance program that is specific to your organization. We have more than 100 years of combined experience in defending clients against allegations that could result in significant fines, imprisonment, and damage to their reputations. Call our healthcare fraud defense lawyers today at 888-402-4054, or contact us online to schedule a confidential consultation.

Links:

https://www.fraud-magazine.com/article.aspx?id=4294976280
https://www.law.cornell.edu/uscode/text/31/3729