Amanda S. Marshall Former U.S. Attorney (Local Counsel)
Lynette Byrd Former Assistant U.S. Attorney
Roger Bach Former Special Agent (OIG & DEA)
Joe Brown Former U.S. Attorney
Medicaid Fraud Lawyer
Medicaid Fraud Control Units (MFCUs) and the U.S. Department of Justice Are Aggressively Targeting Providers for Medicaid Fraud
Each year, Medicaid pays more than $800 billion to subsidize the cost of healthcare for low-income individuals and other qualifying patients. According to the Centers for Medicare and Medicaid Services (CMS), more than 20% of these payments are fraudulent. This substantial percentage has made combatting Medicaid fraud a top federal law enforcement priority, and federal authorities are actively working with Medicaid Fraud Control Units (MFCUs) across the country to uncover and prosecute cases of suspected fraud.
If you are facing scrutiny from an MFCU, the U.S. Department of Justice (DOJ), the Office of Inspector General (OIG), or any other authority, you need experienced legal representation. Medicaid fraud investigations present substantial risks, and facing federal charges for Medicaid fraud can have severe consequences. The DOJ can prosecute Medicaid fraud cases civilly or criminally, and allegations of Medicaid fraud can lead to professional disciplinary action as well.
Our Lawyers Are Experienced in Medicaid Fraud Enforcement and Defense
At Oberheiden P.C., our lawyers are experienced in Medicaid fraud enforcement and defense. Several of our Medicaid fraud lawyers previously served as healthcare fraud prosecutors at the DOJ. As a result, we understand Medicaid fraud investigations from the government’s perspective, and we rely on these insights to execute efficient and strategic defenses for our clients.
If you, your practice, or your business is under investigation for Medicaid fraud, if you are facing a Medicaid audit, or if you have been indicted on charges of defrauding Medicaid, it is extremely important that you speak with an experienced lawyer as soon as possible. Our attorneys represent healthcare providers nationwide, and we can arrange for you to speak with one of our lawyers immediately.
Put our highly experienced team on your side
Dr. Nick Oberheiden
John W. Sellers
Former Senior Trial Attorney U.S. Department of Justice
Joanne Fine DeLena
Former Assistant U.S. Attorney
Lynette S. Byrd
Former Assistant U.S. Attorney
Former U.S. Attorney
Aaron L. Wiley
Former Federal Prosecutor
Former Special Agent (OIG)
Former Supervisory Special Agent (FBI)
Former Special Agent (FBI & IRS-CI)
Kevin M. Sheridan
Former Special Agent (FBI)
Former Supervisory Special Agent (FBI)
Dennis A. Wichern
Former Special Agent-in-Charge (DEA)
Understanding What Constitutes Medicaid Fraud
When facing scrutiny from an MFCU or federal authorities, it is important to have a clear understanding of what constitutes Medicaid fraud. Importantly, while intentionally overbilling Medicaid is one form of fraud, proof of intent is not required to establish civil liability. As a result, even providers that have inadvertently overbilled Medicaid can face substantial penalties—in addition to facing liability for repayment of overbilled amounts.
With this in mind, the following are all examples of billing errors and oversights that can lead to allegations of Medicaid fraud:
Billing for Unnecessary Services or Items – Medicaid reimbursement is only available for services and items that qualify as “medically necessary” under the Medicaid guidelines. Billing for non-qualifying services or items—even unintentionally—constitutes Medicaid fraud.
Billing for Services or Items Not Provided – Billing for services or items not actually provided to patients is also considered a form of Medicaid fraud. Here, too, providers can face civil enforcement action for unintentional violations, including violations committed by their billing personnel or third-party billing administrators.
Unbundling Medicaid-Eligible Services or Items – When related services or items are covered under a single Medicaid billing code at a discounted rate, providers must use this billing code rather than billing for each service and item individually. Failing to do so, which is referred to as “unbundling,” is a common trigger for Medicaid fraud audits and investigations.
Upcoding Medicaid-Eligible Services or Items – Similar to unbundling, “upcoding” involves billing for Medicaid-eligible services or items at a falsely inflated rate. Upcoding can either involve billing for services at a higher level of complexity than the services actually provided or billing for a longer duration than the actual patient visit or interaction.
Card Sharing – Card sharing involves treating non-Medicaid-eligible patients and seeking reimbursement using another patient’s Medicaid identification card to seek reimbursement. Even if patients fraudulently present others’ cards when seeking treatment, providers have a duty to verify their patients’ identity and reimbursement eligibility.
Collusion with Medicaid Beneficiaries and Non–Beneficiaries – Colluding with Medicaid beneficiaries and non-beneficiaries to bill for unnecessary and ineligible services and items is a form of Medicaid fraud that can lead to criminal prosecution under the False Claims Act and other federal laws.
Drug Diversion – Doctors, nurses, and others who are accused of writing false and unnecessary prescriptions can face multiple federal charges. Along with diversion charges under the Controlled Substances Act, this includes Medicaid fraud charges under the False Claims Act and healthcare fraud statute (18 U.S.C. Section 1347).
Offering, Soliciting, Paying, or Accepting Kickbacks – The Anti-Kickback Statute and Stark Law prohibit doctors and other providers from offering, soliciting, paying, or accepting kickbacks from Medicaid-reimbursed funds. While the Stark Law is exclusively a civil statute, the Anti-Kickback Statute includes provisions for both civil and criminal enforcement.
Billing for Ineligible Beneficiaries – Seeking Medicaid reimbursement on behalf of a patient who is ineligible for program coverage is also considered a form of Medicaid fraud. Even if well-intentioned, seeking coverage for an ineligible beneficiary can lead to serious criminal allegations and present risks for substantial fines and imprisonment.
How the Government Investigates and Prosecutes Medicaid Fraud
MFCUs and federal authorities use a variety of enforcement mechanisms to investigate and prosecute cases of suspected Medicaid fraud. Even if an audit or “informal” inquiry seems fairly low-risk, these types of inquiries can quickly lead to full-blown criminal Medicaid fraud investigations. As a result, it is important to take all inquiries very seriously, and this starts with putting an experienced Medicaid fraud lawyer on your side.
At Oberheiden P.C., we handle all government Medicaid fraud enforcement matters, including:
Medicaid Fraud Audits – We have guided numerous healthcare providers through the Medicaid audit process. When conducting audits, auditors are looking for evidence of any and all forms of billing fraud, and they will generally err on the side of pursuing recoupments. Auditors also have the authority to refer cases for civil or criminal prosecution when they believe that further enforcement action is warranted.
Medicaid Fraud Investigations – Medicaid fraud investigations conducted by MFCUs, the DOJ, OIG, and other authorities present substantial risks for participating providers. Even if a targeted provider has not intentionally overbilled Medicaid, improper billings can still lead to recoupments, fines, and other civil penalties.
Civil Medicaid Fraud Enforcement Actions – Civil Medicaid fraud enforcement actions typically follow investigations that uncover evidence of unintentional billing violations. Depending on the circumstances involved, civil enforcement actions can lead to recoupments, fines, prepayment review, Medicaid exclusion, and other penalties.
Criminal Medicaid Fraud Indictments and Trials – If an investigation uncovers evidence of intentional Medicaid fraud, this can trigger a criminal indictment. Along with financial risks, criminal Medicaid fraud charges also present the risk for federal imprisonment.
Medicaid Fraud Appeals – Both providers and the government can pursue Medicaid fraud appeals. Along with experience representing clients during audits, investigations, and civil and criminal enforcement proceedings, we have substantial experience at the appellate level as well.
When to Hire a Medicaid Fraud Lawyer
So, when should you hire a Medicaid fraud lawyer? If you are facing an audit or investigation, you should engage defense counsel promptly. These inquiries can be dangerous, and avoiding unnecessary consequences requires an informed and strategic approach. Likewise, if you are facing civil or criminal charges for Medicaid fraud, you need to speak with a lawyer immediately. While you may have defenses available, you will need to begin working with an experienced lawyer right away to present the strongest defense possible.
FAQs: Defending Against Accusations of Medicaid Fraud
Why Am I Under Investigation for Medicaid Fraud?
MFCUs and other authorities conduct Medicaid fraud investigations for a variety of reasons. Your investigation could be a result of random selection, or it could have been triggered by a complaint from a patient or other party. When you engage our firm to represent you, one of our first steps will be to understand why you are being targeted.
What Are the Risks of Facing a Medicaid Fraud Audit or Investigation?
Facing a Medicaid fraud audit or investigation presents substantial risks. Along with liability for fines and recoupments, these inquiries can also result in loss of Medicaid program eligibility, professional discipline, and even criminal prosecution.
What is a Medicaid Fraud Control Unit (MFCU)?
Medicaid Fraud Control Units (MFCUs) are government authorities that investigate and assist with the prosecution of Medicaid fraud. They operate in all 50 states, Washington D.C., Puerto Rico, and the U.S. Virgin Islands.
Do I Need a Lawyer if I Have Been Contacted By an MFCU?
Yes, if you have been contacted by an MFCU, you should contact a lawyer promptly. You may be under investigation for Medicaid fraud; and, if so, you will need to begin working with your lawyer immediately to execute an effective defense.
What Should I Do if I Have Committed Medicaid Fraud?
If you are concerned about facing criminal charges for Medicaid fraud, you should discuss your situation with a lawyer immediately. In this scenario, a proactive approach is generally best, though you will need to be extremely careful to avoid mistakes that could enhance your exposure to fines, imprisonment, and/or other penalties.
Speak with a Medicaid Fraud Lawyer at Oberheiden P.C.
If you need to speak with a Medicaid fraud lawyer, we encourage you to contact us promptly for more information. Call 888-680-1745 or send us a message online to schedule an appointment at Oberheiden P.C. today.
Necessary cookies help make a website usable by enabling basic functions like page navigation and access to secure areas of the website. The website cannot function properly without these cookies.
Preference cookies enable a website to remember information that changes the way the website behaves or looks, like your preferred language or the region that you are in.
Statistic cookies help website owners to understand how visitors interact with websites by collecting and reporting information anonymously.
Marketing cookies are used to track visitors across websites. The intention is to display ads that are relevant and engaging for the individual user and thereby more valuable for publishers and third-party advertisers.
Unclassified cookies are cookies that we are in the process of classifying, together with the providers of individual cookies.