Wade McFaul Healthcare Fraud Team Former HHS-OIG Assistant Special Agent-in-Charge
If you’re facing an investigation for phantom billing, or up-coding, or if you stand accused of billing for medically unnecessary services, it is crucial that you engage attorneys who are well-versed in your industry. Such proficiency facilitates an immediate and strategic defense when faced with a crisis.
Being implicated in Medicare fraud, a federal felony, could expose you to substantial financial liabilities. The potential charges and threats associated with being accountable for healthcare fraud defense under Medicare, Medicaid, Tricare, and other systems, necessitate that you invest in a robust and strategic defense plan. The repercussions can be drastic, including being stigmatized as a criminal by the government or shouldering heavy civil liability, jeopardizing the business you’ve built. Consult with us to understand how our stellar track record can be utilized in crafting a plan to safeguard your reputation.
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A Medicare/Medicaid Fraud Defense Team You Can Trust
The attorneys at Oberheiden, P.C. have a successful history of defending a broad range of clients in the healthcare sector, from physicians and practice owners to healthcare marketing companies, against numerous legal challenges. See our unblemished healthcare investigation track record for yourself.
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)
Free Consultation
Oberheiden, P.C. assists clients in investigations nationwide. When you call us we will inform you how our Emergency Defense Package will apply to your case. The Emergency Defense Package has been developed by experienced counsel over years and is designed to provide instant relief to targets of investigations. The Emergency Defense Package contains several proven steps to take over control and not be jostled by the government. Call us today and benefit from our experience and industry knowledge.
Facing criminal charges for Medicare fraud can be a daunting prospect, but one you don’t have to navigate alone. An accomplished criminal defense attorney, particularly one well-versed in healthcare fraud cases, becomes your ally. These legal professionals delve into the complex web of healthcare laws and Medicare regulations, wielding a wealth of knowledge crucial to your defense.
When dealing specifically with health care fraud charges, the stakes are exceptionally high. The complexity of the healthcare system, combined with stringent federal regulations, means that even unintentional errors can result in serious accusations. From issues like billing errors or misunderstanding Medicare’s strict guidelines to more serious offenses like intentionally falsifying information and misleading patients or the government, all fall under the umbrella of federal health care fraud.
Your healthcare fraud lawyer will understand the intricacies of these charges, guide you through the legal process, and work tirelessly to protect your interests, professional standing, and freedom. They are equipped to evaluate your specific charges, dissect the evidence against you, and craft a targeted defense strategy unique to your situation. In any federal health care fraud case, remember this: the burden of proof is squarely on the prosecution’s shoulders.
As such, a capable healthcare fraud lawyer is indispensable for medical professionals facing federal health care fraud charges. They challenge every piece of evidence, question the prosecution’s case’s solidity, and tirelessly work to uphold your rights at every turn. Your defense won’t solely focus on escaping a conviction. Should the situation require, mitigating potential penalties even in the event of a conviction is an equally critical aspect of the criminal defense plan. Your healthcare fraud lawyer will strive to present the strongest possible defense against federal health care fraud charges and achieve the best possible outcome for you.
What Constitutes Medicare Fraud?
Medicare fraud, an issue within the broader context of health insurance, refers to the submission of false or fictitious claims to a governmental healthcare program. This could occur in several ways, one of which is ‘unbundling,’ where services that should be billed as a single procedure are separated and billed individually. According to government statistics, claims of approximately $50 billion per year, which may include instances of unbundling, are considered suspicious and subject to Medicare fraud investigation. Thus, no matter how well you think you have organized your practice and operations, the chances of being audited by Medicare eventually are real, especially if your practice is successful and you submit high-volume claims to the Centers for Medicare and Medicaid Services (CMS). In particular, the following statutes form the basis for Medicare investigations:
False Claims Act
Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment to which the healthcare provider is not entitled can lead to serious legal consequences. For example, a laboratory submits claims to Medicare for a higher level of services than actually provided (See, 31 U.S.C. Sect. 3729-3733). Such fraudulent activities are not just a breach of trust, but also a violation of the False Claims Act (FCA), and can have a criminal component (see 18 U.S.C. Sect. 287).
The FCA is a critical piece of legislation in the fight against Medicare fraud. Enacted during the Civil War and significantly amended in the 1980s, it is designed to protect the government from being overcharged or sold substandard goods and services. This act is the government’s primary litigation tool for recovering losses caused by fraud. Notably, the FCA includes provisions for treble damages and penalties, which can result in substantial financial penalties for convicted fraudsters. It is a potent tool in the government’s arsenal to combat healthcare fraud, including Medicare and Medicaid fraud.
In many cases, it is the whistleblowers who shed light on these fraudulent practices. These brave individuals, often employees or insiders within an organization, play a pivotal role in uncovering and reporting Medicare fraud. Under the FCA’s qui tam provision, whistleblowers can file a lawsuit on behalf of the government if they uncover evidence of fraudulent activities. If the case is successful, the whistleblower may be eligible for a percentage of the recovered funds, providing a strong incentive for individuals to come forward with valuable information. However, stepping forward as a whistleblower can come with its own set of risks, including potential retaliation and professional consequences. Consequently, it is crucial for potential whistleblowers to seek legal counsel to navigate these complexities and protect their rights under the whistleblower protections provided by the FCA and other relevant laws.
The Role of a Health Care Fraud Attorney in False Claims Act Cases
After being accused under the False Claims Act, the next logical step is to seek the counsel of a competent health care fraud attorney. These professionals, with their specialized understanding of the FCA and healthcare legislation, play a critical role in guiding both healthcare providers and whistleblowers through the complexities of a fraud case. Health care fraud attorneys work diligently to defend their clients, aiming to dismiss or reduce the charges and minimize potential penalties. As for the whistleblowers, they navigate the process of filing a qui tam lawsuit, ensuring their client’s rights are protected and that they are insulated as much as possible from retaliation or professional fallout. Whether facing allegations or reporting suspected fraud, partnering with a knowledgeable health care fraud attorney is an indispensable component of the process when dealing with cases related to the False Claims Act.
Navigating False Claims Act Cases: The Role of Health Care Fraud Attorneys
When facing allegations under the False Claims Act, seeking the guidance of a skilled health care fraud attorney, also known as a criminal lawyer, is a crucial step forward. With their specialized understanding of the False Claims Act (FCA), healthcare legislation, and the intricacies of fraud cases, these attorneys play a critical role in guiding both healthcare providers and whistleblowers through the complexities of double billing, prescribing practices, and other types of healthcare fraud. Their diligent efforts are focused on defending clients, striving to dismiss or reduce charges and minimize potential penalties, including the risk of a prison sentence. For whistleblowers, health care fraud attorneys navigate the process of filing a qui tam lawsuit, ensuring their client’s rights are protected and shielding them as much as possible from retaliation or professional repercussions. Whether you find yourself accused or are reporting suspected fraud, partnering with a knowledgeable health care fraud attorney is an indispensable component of navigating cases related to the False Claims Act. This collaboration provides peace of mind and increases the chances of achieving a favorable outcome in your legal proceedings.
Stark Law (Self-Referrals)
Physician self-referral is a practice where a physician refers a patient to a medical facility in which they have a financial interest. It’s often seen as a conflict of interest, as it can incentivize overutilization of services, escalating healthcare costs, and potentially compromising patient care by influencing decision-making based on financial gain rather than the patient’s best interest. The Stark Law was enacted to address issues related to physician self-referral within Medicare. It places limitations on the ability of physicians to refer patients for designated health services payable by Medicare to an entity with which the physician, or a family member, has a financial relationship, unless an exception applies.
For instance, the Stark Law specifically prohibits referrals for certain designated health services to an entity in which the physician or the physician’s immediate family has an ownership or financial interest or compensation arrangement. An example would be a surgeon who refers business to an MRI clinic that his wife owns (See, 42 U.S.C. Sect. 1395nn). There are, however, safe harbor exceptions outlined in 42 C.F.R. Sect. 1001.952.
Violation of the Stark Law can lead to severe penalties, including fines and exclusion from federal healthcare programs. Therefore, understanding and properly navigating the complexities of physician self-referral is crucial in the healthcare industry.
Anti-Kickback Statute
Knowingly soliciting, paying, and/or accepting any form of remuneration to induce or reward referrals for items or services reimbursed by federal healthcare programs, e.g. an arrangement that is not covered by regulatory safe harbors and whereby cash or other benefits are offered or exchanged for referrals. See, 42 U.S.C. 1320A-7b(b).
Civil Monetary Penalties Law
Examples for civil monetary penalties to arise are presenting a claim that the claimant knew or should have known is for an item or service not provided as claimed or that is false and fraudulent; presenting a claim that the claimant knew or should have known is for an item or service that is not reimbursable by Medicare; or any violation of the Anti-Kickback Statute.
Civil monetary penalties authorize the government to charge up to $ 50,000 per each false claim plus up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, solicited, paid, or received. See, 42 U.S.C. Sect. 1320a-7a
Criminal Fraud Statute
Criminal law is a vital and complex part of our legal system that governs behavior deemed damaging to society as a whole, including healthcare fraud. It prescribes conduct perceived as threatening, harmful, or otherwise endangering to the property, health, safety, and moral welfare of people. Notably, healthcare fraud falls under the umbrella of criminal law due to its detrimental impact on the integrity of healthcare systems and public trust.
Now, moving forward with the existing discussion: Whoever knowingly or willfully executes or attempts to execute a scheme to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program in connection with the delivery of or payment for healthcare benefits, items, or services, shall be fined or imprisoned of up to 10 years, or both. This is prescribed under 18 U.S.C. Sect. 1347 of the criminal law.
Remember, healthcare fraud is not limited only to healthcare providers but extends to “anyone,” including physicians, nurses, practice managers, non-licensed individuals, practice owners, healthcare businesses, and even institutions. In the realm of criminal law, everyone is equally accountable for their actions and must face appropriate legal consequences for healthcare fraud.
What are the Penalties?
Medicare fraud is investigated by the Office of Inspector General (OIG), the Department for Health and Human Services (HHS), the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), Medicaid Fraud Control Units (MFCUs), and State Medicaid Agencies in cooperation with the Healthcare Fraud Prevention and Enforcement Action Team (HEAT), the General Services Administration (GSA), and the Centers for Medicare and Medicaid Services (CMS).
If found guilty, targets of investigations may be exposed to recoupment requests, non-payment of future claims, civil fines of up to $ 11,000 per false claim, exclusion from federal healthcare programs, treble damages, attorney fees, criminal fines, criminal indictment, or incarceration in a federal prison.
Liability does not require a specific intent to violate the law; in fact, the government does not even need to prove actual knowledge of the wrongfulness of the transaction.
Defending Medicare Fraud: Your Attorney
A health care fraud attorney specializes in navigating the labyrinth of laws and regulations surrounding healthcare fraud. They leverage their expertise to defend clients against accusations of fraudulent activities and to guide them through complex legal processes. An adept health care fraud attorney can scrutinize the evidence, identify potential flaws in the prosecution’s case, and develop a robust defense strategy, all the while working tirelessly to safeguard their client’s rights. Their profound knowledge of the intricacies of healthcare laws coupled with their litigation skills make them indispensable in the face of such serious allegations. Hiring a health care fraud attorney could be the difference between a favorable outcome and severe legal repercussions.
This expertise proves especially valuable when dealing with the complex issue of healthcare reimbursement. A labyrinth in its own right, reimbursement involves intricate billing practices that vary based on the services provided and the insurer’s policies. Misunderstandings or inaccuracies in billing for reimbursement can inadvertently lead to allegations of healthcare fraud. To effectively navigate the complexities of these procedures, a health care fraud attorney’s understanding of the minutiae of healthcare billing becomes crucial. They are well-versed in the varying reimbursement rates for different procedures and can scrutinize the billing codes used by healthcare providers to ensure they align accurately with the services rendered. They can identify potential discrepancies that could be misconstrued as fraudulent activity. This understanding of reimbursement systems allows them to build a more compelling defense strategy, addressing each allegation specifically and comprehensively. Even when dealing with the convoluted world of healthcare reimbursement, a skilled health care fraud attorney can serve as an essential ally, protecting providers from unwarranted accusations and penalties.
This is How We Defend Medicare Fraud
When you hire the medicare fraud defense attorneys and former government officials of Oberheiden, P.C., you will notice that we concentrate our defense against False Claims Act, CMS Exclusion, Stark Law, Anti-Kickback violations, and fraud charges by focusing on three core abilities.
Industry Knowledge. We have industry knowledge. Because Medicare fraud often stems from billing and coding errors, an intrinsic understanding of CMS protocols is critical. Don’t let misinterpretations of coding policies or missed updates to billing changes expose your practice. You need attorneys that understand billing and coding violations. Our healthcare fraud defense attorneys have analyzed, reviewed, and defended close to 500,000 billed claims. Similarly, if you are accused of Stark Law violations, you need medicare fraud defense attorneys that understand the safe harbor exceptions to get your case dismissed.
Government Experience. We have government experience. The difference between liability and human error is often a fine line that requires convincing negotiation skills and attention to details. The medicare fraud defense lawyers and former government officials of Oberheiden, P.C. have proven healthcare and law enforcement experience. Our defense attorneys have extensive knowledge and competence in handling any fraud allegations in the healthcare industry. See for yourself and look at our track record.
Civil, not Criminal. We want to keep investigations civil, not criminal. Our attorneys are able to persuade the government those errors, if they exist, were not done intentionally and willfully, but by accident and human error. Doing so is critical because, in each fraud investigation, the government has two choices: to investigate you to seek recoupments or to prosecute and indict you and seek imprisonment. The law provides for both.
Government Investigation: Civil or Criminal?
One of the predominant questions clients ask us when they call Oberheiden, P.C. for help is to determine if the government investigation against them is civil or criminal; that is, whether the government is seeking monetary remedies or seeking criminal indictments and imprisonment. Healthcare fraud statutes provide for both, making the issue of civil versus criminal a critical threshold question. About 1,400 individuals are indicted in federal court for healthcare fraud each year and more than 2,500 individuals are under Medicare criminal investigation.
A key component of these government investigations is the audit. Audits play a critical role in the identification and prevention of Medicare fraud. They are typically undertaken by the Office of Inspector General (OIG) or the Centers for Medicare & Medicaid Services (CMS). These audits scrutinize healthcare providers’ billing practices and procedures to ensure compliance with relevant laws and regulations.
Different types of audits are used, each with a unique purpose. Routine audits aim to ensure that Medicare funds are being spent appropriately, while targeted audits often follow suspected fraudulent activity. Both types of audits can lead to civil or criminal charges if evidence of fraud is uncovered.
The process of these audits can be complex and rigorous. Providers subject to audits must be able to substantiate their billing claims with detailed documentation. If the audits reveal inconsistencies or improper billing practices, severe penalties can result, including hefty fines and potential exclusion from federal health care programs.
Moreover, audits can happen unexpectedly, making it essential for providers to maintain an ongoing compliance program to prepare for such situations. By doing so, providers can mitigate the risks associated with audits and be better positioned to navigate through the audit process should it occur. Engaging an experienced Medicare Fraud Defense Lawyer can be invaluable during audits, offering guidance and defense strategies to navigate the complexities of the audit process.
How do we know all of this? Often times, when we first talk to our new clients and hear their side of the story, we develop a good sense. Years of experience combined with the insight and knowledge of our former government officials allow us to catch certain details and nuances of the investigation that do not strike the general audience as relevant. For example, we pay close attention to how our clients had been notified about the investigation, by which government agency they were contacted, and which government official is in charge of the investigation. The mere involvement of a prosecutor or a federal agency does not mean that the case is a criminal investigation.
Call us today to discuss your case with our Medicare fraud lawyers. All initial consultations are free and confidential. We want you to gain relief and to move on with your life. Let us handle your case.
Who Is Investigated?
Healthcare fraud exposes not just individual providers and business owners, but also entities such as insurance companies. Statutes apply to any individual, business, or insurance company that directly or indirectly contracts with and is paid for services by the United States government. Particularly exposed are service arrangements with the government in the following areas:
Industries:
Hospitals
Home Health Centers
Physician Owned Entities
Healthcare Providers (e.g. Physicians)
Laboratories (toxicology, biologics)
Pharmacies (incl. compound)
Medical Device Companies
Recent Examples:
Medicare Fraud Strike Force charges 90 individuals
Medicare Fraud Strike Force charges 89 individuals
Doctor Admits Taking Bribes in Test-Referral Scheme with Lab
Owner of Nursing Agency Convicted of Multi-Million Dollar Fraud Scheme
Principal in $28.3m Medicare Fraud Scheme Sentenced to 11 Years in Prison
Defense of Medicare laboratory against investigations by the Department of Justice and the U.S. Attorney’s Office for alleged Medicare Fraud Result: No civil or criminal liability, case dismissed.
Defense of a healthcare services company against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged False Claims Act and Stark Law violations Result: No civil or criminal liability, case dismissed.
Defense of Medicare laboratory against investigations by the Department of Health and Human Services and the Office of Inspector General for alleged Healthcare Fraud. Result: No civil or criminal liability, case dismissed.
Defense of nationally operating healthcare company against an investigation by the Department of Defense for alleged Tricare fraud. Result: No civil or criminal liability, case dismissed.
Defense of healthcare marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare violations. Result: No civil or criminal liability, case dismissed.
Defense of a laboratory against an investigation by various branches of the federal government for alleged fraud. Result: No civil or criminal liability, case dismissed.
Defense of physician owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged fraud. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Department of Justice for alleged fraud. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged Stark Law violations. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged False Claims Act violations. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by various branches of the federal government for alleged False Claims Act, Stark Law, and Medicare violations. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged fraud. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Department of Defense for alleged Tricare fraud. Result: No civil or criminal liability, case dismissed.
Defense of a physician owned entity against an investigation by the Department of Justice for alleged Medicare Fraud. Result: No civil or criminal liability, case dismissed.
Defense of physician owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations. Result: No civil or criminal liability, case dismissed.
Defense of healthcare management organization against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged Medicare Fraud. Result: No civil or criminal liability, case dismissed.
Defense of nationally operating laboratory against an investigation by the Office of Inspector General for alleged fraud. Result: No civil or criminal liability, case dismissed.
Medicare Appeals Process
With the complexity of the regulations that make up Medicare rules, including its appeals process, there is no substitute for having a lawyer that understands the intricacies of both the law and the Medicare programs. Many healthcare providers, however, believe they can rely on billing professionals or other groups without legal experience to file their Medicare appeals.
The fact of the matter is that filing Medicare appeals without an experienced medicare fraud attorney can lead to costly risks, mistakes, and penalties that could have been avoided with the proper understanding and knowledge of the law.
Medicare appeals take place in the following five steps:
Redetermination by a Centers for Medicare & Medicaid Services (CMS) contractor
Reconsideration by a qualified independent contractor
Hearing before an administrative law judge
Review by an appeals council
Judicial review in the federal district court
Each step in the Medicare appeals process requires the correct evidence, argument, and punctuality to ensure that errors are not made that affect the rest of the process. Making mistakes in one step of the process may result in significant problems.
Don’t let mistakes in the appeals process create irreparable issues for you later on. At Oberheiden, P.C., our Medicare fraud attorneys are experienced with the Medicare appeals process and have a long track record of successfully defending clients facing Medicare fraud charges.
Contact the Medicare Fraud Defense Team at Oberheiden P.C. Today
Your consultation is free, and you will only speak with a Sr. attorney at our firm. Call now.
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