Healthcare fraud investigations are normally initiated after a government agency conducts an audit or after a whistleblower complains of alleged fraud. Today, the government has advanced computer software which can flag billing anomalies and irregularities. This will often lead to a full audit and investigation of the business in question. The business owner will then likely receive notice and be asked to submit billing documentation. Any clinic owner or physician who becomes aware of such an investigation should contact an experienced health care fraud attorney to assist in dealing with the government agency handling the investigation.
Federal Health Care Fraud Lawyer
Federal Health Care Fraud Attorney
The lawyers at Johnson/Citronberg have years of experience defending clinic owners, doctors, and nurses against health care fraud allegations, including Medicare investigations and criminal charges. Criminal defense lawyers at our firm has been successful in getting the government to drop investigations altogether, obtaining favorable civil settlements, and stopping the government from pursuing criminal charges.
CONTACT JOHNSON/CITRONBERG | (855) 959-4003
Where We Practice
Whether you are involved in a civil investigation or a criminal case, we understand the importance of protecting your reputation in the medical community, maintaining your Medicare number, and protecting assets that you worked hard to achieve.
Often, fraud investigations are driven by a loss to private insurance carriers, Medicare, Medicaid or other providers. This can result in not only criminal charges, but costly civil litigation. A major source of contention deals with medical coding, as one procedure can often have different codes, and the government agency or insurance company will argue that the provider billed for a more costly service.
Any business that bills Medicare, Medicaid, or Tricare can find itself being audited or investigated by one of the following government agencies:
- Centers for Medicare and Medicaid Services (CMS)
- AdvanceMed
- Medicare Fraud Strike Force
- Federal Bureau of Investigation (FBI)
- Department of Justice (DOJ)
- Office of the Inspector General (OIG)
These investigations can be civil or criminal in nature, each carrying their own potential consequences:
Civil Penalties:
- Large fines/restitution
- Loss of ability to bill Medicare/Medicaid
- Loss of ability to practice medicine
Criminal Penalties:
- Lengthy prison sentences
- Large fines/restitution
- Forfeiture of assets
- Loss of medical license
Federal Laws Involved in Health Care Fraud Cases
In any health care investigation or case, there are a number of federal laws that may be at play. The following are the most common federal laws that every health care provider should be aware of:
- False Claims Act: This federal law prohibits knowingly submitting bills to the government that are fraudulent.
- Stark Law: This law prohibits the payment of referral fees in connection with medical services or supplies.
- Anti-Kickback Statute: This is commonly referred to as the “AKS” and prohibits any health care provider from paying a referral fee (or kickback) in exchange for a referral.
- Healthcare Fraud Statute: This law makes it illegal for anyone to target and defraud a government healthcare program, such as Medicare and Medicaid.
- Controlled Substances Act: If the healthcare provider was involved in prescribing a Scheduled drug, especially Schedule II pain killers, the Government may pursue drug charges under the Controlled Substances Act.
Types of Health Care Fraud
Health care fraud can take on many forms. The most common forms are listed below:
- Medical billing errors
- Charging for services not performed
- Overbilling for medical services
- Inflating medical procedure costs
- Falsifying patient records
- Performing unnecessary procedures
Civil vs. Criminal
The line between a civil offense and a criminal offense is often blurry. Whether the government chooses to pursue a criminal case can depend on the following factors:
- The healthcare provider’s ability to pay a fine/restitution
- The provider’s role in the organization that allegedly committed the fraud
- The degree of intent to violate federal law
- The degree of harm to any patients
- The amount of fraud in question
- How systemic the alleged fraud is
- Whether the healthcare provider changed its behavior before or after the investigation started
- Self-disclosure
- Prior instances of alleged fraud
- A viable plan to change company procedures
A good healthcare fraud defense lawyer will work to keep any civil investigation from becoming criminal in nature. This often involves the defense lawyer from working to show that the billing irregularities were unintentional, developing a repayment plan, and proposing a game plan to ensure that there are no irregularities in the future.
How We Can Help
Our health care fraud attorneys understand the complexities of medical billing. We will work diligently to build a strong case strategy, reviewing patient files, examining government claims, interviewing patients and enlisting help from expert witnesses. Our goal is to help you achieve the best possible outcome to your situation.
No matter how complex the charges, we have the skill and knowledge to assist you. Contact us at 855-959-4003, or by e-mail using our secure online form. For our offices in Alexandria, Virginia, and Atlanta, Georgia, we are able to represent clients throughout the United States.
