Wade McFaul Healthcare Fraud Team Former HHS-OIG Assistant Special Agent-in-Charge
For healthcare providers that rely on benefit programs such as Medicare, Medicaid, and Tricare, ensuring compliance with all applicable billing guidelines can be a constant struggle. From unclear requirements to personnel changes and business dealings with third parties, there are numerous factors that can make it extremely difficult to remain compliant at all times.
Nonetheless, remaining compliant is a necessity. For physicians, pharmacists, hospice owners, and other healthcare providers, the consequences of billing violations can be substantial. From civil monetary penalties and program exclusion – to loss of licensure and even federal imprisonment – accusations of billing fraud can impact all aspects of providers’ professional and personal lives. With healthcare fraud enforcement remaining a top law enforcement priority, providers across the country are facing investigations or worse. Many are experiencing first-hand the effects of failing to successfully defend against billing fraud allegations.
Highly Experienced in Healthcare Fraud Defense & Medical Billing Fraud Defense
Our firm is highly experienced in representing healthcare providers in billing fraud investigations and prosecutions. Working alongside licensed practitioners, executives, board members, key personnel, and company owners, our attorneys execute comprehensive defense strategies designed to address our clients’ cases with the goal of extinguishing civil or criminal liability. When providers get us involved early – before or during their investigations – we resolve the majority of our cases without our clients being charged for billing fraud or other related offenses.
Put our highly experienced team on your side
Dr. Nick Oberheiden
Founder
Attorney-at-Law
John W. Sellers
Former Senior Trial Attorney U.S. Department of Justice
Local Counsel
Joanne Fine DeLena
Former Assistant U.S. Attorney
Local Counsel
Lynette S. Byrd
Former Assistant U.S. Attorney
Partner
Amanda Marshall
Former U.S. Attorney
Local Counsel
Aaron L. Wiley
Former Federal Prosecutor
Local Counsel
Roger Bach
Former Special Agent (OIG)
Gamal Abdel-Hafiz
Former Supervisory Special Agent (FBI)
Chris Quick
Former Special Agent (FBI & IRS-CI)
Kevin M. Sheridan
Former Special Agent (FBI)
Ray Yuen
Former Supervisory Special Agent (FBI)
Dennis A. Wichern
Former Special Agent-in-Charge (DEA)
Common Billing Fraud Allegations in Medicare, Medicaid, and Tricare Investigations
“Billing fraud” is a broad term that encompasses a range of violations involving healthcare providers’ reimbursement requests submitted to Medicare, Medicaid, Tricare, and other benefit programs. Most of these violations are prosecuted as civil or criminal offenses under the False Claims Act, although federal authorities can pursue billing fraud charges under a variety of other statutes as well. This includes the Anti-Kickback Statute (which applies to all healthcare providers), and the Stark Law (which applies specifically to billings that include compensation for physician “self-referrals”). Some of the most common allegations in billing fraud investigations under these statutes include:
Billing for Kickbacks and Referral Fees – Billing regulations prevent healthcare providers, pharmaceutical companies, durable medical equipment (DME) companies, and other program participants from seeking reimbursement for payments that constitute kickbacks and referral fees.
Billing for Medically-Unnecessary Services – Federal healthcare benefit programs are intended to help cover the cost of medically-necessary services, medications, and medical equipment. Billing for medically unnecessary services or supplies is considered a form of fraud. This includes billing for wrong-site procedures and for the wrong level of service.
Billing for Non-Allowable Costs – Some costs are eligible for reimbursement, and some are not. Reporting non-allowable costs is a common allegation in federal billing fraud investigations.
Billing for Services, Medications, or Equipment Not Provided – In addition to prosecuting providers who bill for unnecessary services, federal authorities also vigorously pursue providers suspected of billing for services, medications, and medical equipment that were not actually provided to patients.
Billing for Unlicensed or Excluded Services – Medical services provided by unlicensed individuals are generally ineligible for program reimbursement. The same goes for services provided by individuals and entities that have previously been excluded from program participation.
Duplicate Claims – Submitting multiple reimbursement requests for the same service, medication, or medical equipment, either to a single benefit program or to a benefit program and a private healthcare insurer.
Failure to Comply with Conditions of Payment or Secondary Payer Rules – All healthcare program benefit participants are subject to a variety of eligibility conditions. Violating the conditions of eligibility can trigger an obligation to report and refund program overpayments.
Unbundling Services – Under healthcare program billing regulations, many services must be “bundled” for reimbursement at a specific (and typically lower) rate. Unbundling services in order to bill for them individually is a violation that can lead to recoupments, fines, and other penalties.
Up–Coding – Similar to unbundling services, up-coding involves using incorrect billing codes in order to obtain higher reimbursement rates than are provided for under the applicable program billing regulations.
Using the Wrong Billing Code – While often done unintentionally, using the wrong billing code is also a method that some entities use to fraudulently obtain unearned compensation from Medicare, Medicaid, and Tricare.
What Healthcare Providers Need to Know about Billing Fraud: Answers to FAQs
Q: What should I do if I am concerned about billing violations in my business or practice?
If you are concerned that your business or practice may be exposed to liability for billing fraud, it is critical to take a proactive approach to the issue. This means auditing your billing practices, implementing any necessary changes to your compliance policies and procedures, and determining whether you owe any reporting or repayment obligations to Medicare, Medicaid, or Tricare.
Q: What should I do if I have been contacted by state or federal authorities about my program billings?
If you have been contacted by state or federal authorities, you need to seek legal representation. While informal requests for information or “interviews” may seem harmless, sharing any information could be harmful to your defense, and you need to implement a comprehensive strategy designed to protect against the imposition of civil or criminal charges. The agencies that investigate billing fraud include:
State law enforcement agencies
Medicaid Fraud Control Units (MFCUs)
Medicare Fraud Strike Force
Centers for Medicare and Medicaid Services (CMS)
Drug Enforcement Administration (DEA)
Federal Bureau of Investigation (FBI)
U.S. Department of Defense (DOD)
U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG)
U.S. Department of Justice (DOJ)
U.S. Department of Labor (DOL)
Q: What are the penalties for billing fraud?
The penalties for billing fraud can be severe. For example, in a civil enforcement case under the False Claims Act (FCA), a provider can face recoupment, treble (triple) damages, fines of nearly $22,000 per false claim (as of 2017), and program exclusion. In a criminal case under the FCA, the potential penalties include hundreds of thousands of dollars in fines and five years in federal prison for each individual charge.
Q: How often do billing fraud investigations lead to charges and convictions?
According to federal data, only a relatively small percentage of billing fraud investigations lead to indictments, with an even smaller percentage leading to convictions. However, those that avoid prosecution are often those who seek experienced legal representation. Ignoring your investigation is perhaps the best way to put yourself at risk for facing charges.
Put Oberheiden, P.C.’s Medical Billing Fraud Defense Team Experience on Your Side
In healthcare fraud billing investigations, experience matters. You may be up against investigators and prosecutors who focus 100 percent of their time and effort on healthcare fraud enforcement and by the time you find out you are under investigation the government is likely already building its case against you. The healthcare fraud defense team at Oberheiden, P.C. can level the playing field and we can help you take control of your situation. Contact us today to learn more about:
Our notable experience in healthcare law compliance and enforcement
Our past careers as state and federal healthcare prosecutors
Our extensive track record in federal investigations
Our litigation and trial experience at the state and federal levels
To get started, we encourage you to schedule a free and confidential case assessment with our trusted billing fraud attorneys. You can call 888-680-1745 to schedule an appointment, or submit a request online and we will respond as soon as possible.
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