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What Detroit Medical Providers Need To Know About Medicare Fraud

Oberheiden, P.C.
Former Medicare Prosecutors & Defense Counsel

The Investigative Process

Healthcare is one of the most highly regulated industries by the United States government and providers of all sizes and specialties face the high demands of this regulatory environment daily. This is particularly true of providers that accept reimbursement from federal programs such as Medicare, Medicaid, and Tricare, and thereby become susceptible to Medicare fraud investigations. It is crucial, therefore, that such providers understand the government’s investigative process to ensure an efficient and effective strategy of responding to and surviving a Medicare fraud investigation.

Recently, the government has expanded its Medicare fraud investigation operations, and in doing so, has identified specific geographic areas where it believes Medicare fraud to be most prevalent. Detroit is a major focal point for Medicare fraud investigations. This has been made evident by the fact that the United States Department of Justice (DOJ) has designated Detroit as a hot spot for Medicare fraud, and Detroit is one of just nine cities in the country to receive a local Medicare Fraud Strike Force.

Detroit’s local Medicare Fraud Strike Force is a collaborative effort by the DOJ and the Department of Health and Human Services (HHS) that works with local state and federal law enforcement agents to prevent, detect, and investigate Medicare fraud in the region. The Medicare Fraud Strike Force is overseen by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), another joint effort of DOJ and HHS to combat Medicare fraud on a national scale. Any provider that receives a notice of investigation from any of these agencies should immediately retain legal counsel that has experience in dealing with the government in Medicare fraud investigations. Our attorneys at Oberheiden, P.C. have helped many clients faced with such investigations nationwide and are particularly available to help clients in Michigan.

After an investigation occurs, Medicare may seek to recoup payments that were made on improper bills or may seek prosecution by the DOJ U.S. Attorney’s Office. The U.S. Attorney’s office has the discretion of bringing a civil case, a criminal case, or both against providers alleged to have committed Medicare Fraud. Therefore, it is of utmost importance that providers do what they can to avoid the red flags that the government looks for in determining whether to investigate and be ready to respond if faced with an investigation. Such providers must seek legal counsel to ensure fair treatment during the investigation, and possibly the prosecutorial, process.

Not Every Mistake Constitutes Healthcare Fraud

Federal healthcare laws and regulations are complicated, confusing, and constantly changing. Therefore, it is easy to see how a business or practitioner could unintentionally violate one or more rules without even realizing that a violation had occurred. In fact, in our experience as healthcare defense attorneys, we often see well-meaning physicians and business owners facing scrutiny as the result of human or clerical error, lack of organizational oversight, or inexperienced employees. Innocent mistakes do not constitute healthcare fraud and should not lead to criminal liability; to be guilty of healthcare fraud, one must engage in fraudulent activity intentionally. The intent element can be helpful for providers who are ultimately prosecuted by the government after an investigation, but ideally, providers should clear their systems of anything that can create a perception of fraud.

Providers should institute compliance systems that employ regular internal audits and adequate employee training to ensure that they do not become the victim of a human error being construed as fraud. Furthermore, these strategies show the government the provider’s willingness and desire to maintain compliance with all government regulations. That perceptional advantage can go a long way in a Medicare fraud investigation. To best institute these internal programs, providers should seek legal counsel with experience in creating, implementing, and maintaining compliance programs. Our group of former Medicare fraud investigators and prosecutors at Oberheiden, P.C. are profoundly experienced in what it takes to set up such programs.

At Oberheiden, P.C., we understand that innocent mistakes aren’t Medicare fraud. We have helped many clients avoid Medicare fraud charges simply by showing to investigators that suspicious activity was in fact the result of mistakes or misunderstandings and not intentional fraud. Call Oberheiden, P.C. today to speak with one of our attorneys about your investigation.

Oberheiden, P.C.

Comprised of former Assistant United States Attorneys and veteran federal defense attorneys, Oberheiden, P.C. represents doctors, business owners, and other professionals within the healthcare industry facing investigation or prosecution for Medicare fraud. Throughout Michigan and the Mid-West, and especially in Detroit, we help clients when faced with allegations of Medicare fraud, anti-kickback violations, improper billing procedures, and other healthcare fraud allegations.

Oberheiden, P.C.
Compliance – Litigation – Defense

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