The procedures for properly billing Medicaid, Medicare, and private health insurance companies are complicated. With CPT and ICD-9 codes and the interpretations of the code changing annually, it can be difficult to properly bill for services. This is why so many offices turn to private companies to handle their coding and billing. However, even that does not guarantee you will not run into problems. A Medicare billing audit can quickly turn into a criminal investigation if the auditor believes there is evidence of wrongdoing.
Our healthcare fraud defense attorneys stand willing to represent the many different parties who get caught up in audits, investigations, criminal prosecution, and civil litigation, including:
- Doctors and other medical providers, including chiropractors, nurses, diagnostic professionals, pharmacists, dentists
- Pharmaceutical and medical equipment providers, including online pharmacies and durable medical supplies
- Hospitals and their employees, including individual directors, managers, accounting staff
- Home healthcare companies and their staff
Medical Fraud Defense
The rules for billing under Medicare and Medicaid are complex and the process can be difficult to understand. We know that providers can easily trigger civil audits and criminal investigations through innocent mistakes in billing government programs or private insurance, and that investigators automatically suspect doctors even when the billing department of a large health organization made the errors.
Our healthcare fraud attorney’s chief objective is to pre-empt criminal charges against physicians and other healthcare providers by conducting our own investigation to prove there was no intent to defraud. If charges are brought, we aggressively counter the allegations before a jury or negotiate a favorable plea agreement intended to (a) avoid prison and (b) avoid loss of professional licenses.
Home Healthcare Fraud
A large number of high-profile cases have been prosecuted in Florida over the past several years, many of them involving home healthcare agencies and providers. These cases are usually prosecuted at the federal level.
Hospitals & Employees
Our lawyers have represented a number of hospital employees and officers and employees of medical practices in Medicare and Medicaid fraud cases, as well as many physicians and employees caught up in the investigation.
In some instances, both the hospital and individuals are charged criminally, under the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act, or other federal laws, including RICO or conspiracy to commit healthcare fraud. Our hospital fraud defense lawyers emphasize early intervention at the civil audit stage to try to prevent criminal indictments. We also represent clients the defense of related civil RICO lawsuits.
Our experienced trial lawyers have represented all of the following:
- Medical practices and hospital employees
- Doctors and physician groups
- Medical services directors
- Managers and employees of hospital accounting and billing departments
We can capably analyze, investigate, and respond to all allegations, including billing for services not provided, billing for unnecessary services, upcoding and other over-billing, falsified documents, obstruction of justice (destroying evidence), filing false cost reports, or illegal kickbacks in the healthcare industry.
Hospital Fraud — We advise employees, officers, and medical directors of hospitals. Federal charges can result in prison terms and hundreds of thousands in fines for individuals and the hospital charged with fraud. Civil RICO lawsuits can expose the individuals, hospitals or clinics to treble damages. We strive to convince the government not to take any action against our clients, or in the alternative, we argue for non-prosecution agreements, a pre-trial diversion to forego criminal prosecution against the client in exchange for fines and restitution.
But a non-prosecution agreement with the hospital does not prevent the government from charging individuals criminally. It’s important to know that the hospital’s legal counsel, though sympathetic to doctors and staff, is looking out for the interests of the corporation. Individuals caught up in hospital fraud will need their own legal counsel, and the earlier in the process the better.
Pharmacy & Medical Supply Fraud
We also have experience representing online pharmacies and durable medical supply companies under investigation for healthcare fraud.
Our team draws on decades of experience to help clients avert prosecution or defend them against a wide range of allegations and related civil lawsuits:
- Distribution fraud (adulterated drugs, substitute drugs, or repackaging free samples for sale)
- Over-billing for medications or durable medical equipment (e.g., wheelchairs, oxygen tanks, adjustable beds)
- False claims for goods or services not rendered
In particular, the FBI, DEA, and FDA are cracking down on online pharmacy fraud and related crimes, charging pharmacists for distributing drugs without legitimate prescriptions or physicians for prescribing medications over the Internet without ever examining patients. Coupled with fraudulent insurance billing, this can lead to multiple counts of mail fraud or wire fraud, which carry stiff prison terms upon conviction, and sanctions against the provider’s medical license/pharmacist license. Added to the potential penalties may be racketeering charges and accusations of money laundering, along with possible civil fraud litigation with treble damages.
Potential Penalties for Fraud in Florida
State and federal fraud prosecutors are eager to make an example of those caught in the net of a long-term investigation. The potential penalties for conviction are severe; if you have been accused, it is important that you work with a skilled criminal defense attorney to help you answer the charges and punishment you may face. These include:
- Prison: Federal sentences are based on the dollar amount of loss. Fraud valued at $120,000 can carry up to one year in prison, even for a first offense. If the loss exceeds $400,000, presumptive prison terms are two to three years.
- Fines: A federal conviction for Medicare, Medicaid or other healthcare fraud can result in fines equal to twice the loss, up to a $250,000 fine for individuals and up to $500,000 for corporations, whichever is greater.
- Medical sanctions: Physicians or other providers may face loss of their medical license/professional license, and hospitals or individual providers can be barred from future contracts with Medicaid and Medicare.
- Multiple counts: Each false claim is a separate offense. If the investigating agency alleges dozens or hundreds of fraudulent billings, prosecutors can seek the maximum sentence under sentencing guidelines. It is also possible to face state and federal prosecutions for the same allegations.
- RICO prosecutions: Convictions involving fraud under the federal RICO provisions may carry additional criminal penalties and forfeiture of assets.
- Civil lawsuits: If sued civilly under RICO, you may face treble (triple) damages.
Billing For Services Not Provided
Billing errors can occur in any number of ways. Insurance companies, Medicare, and Medicaid become concerned when a pattern of discrepancies emerges during an audit or review.
During a Medicaid or Medicare audit, an investigator will review a wide range of clinic records to determine if the clinic or office was properly staffed and resourced to provide the services it said it provided. Investigators may then interview patients to determine if they received the services the provider billed. Investigators will look for false records and false claims.
An insurance company may analyze the bills of a large number of physicians in the same state looking to see if one provider is using a CPT code far in excess of other physicians. This is another signal of healthcare fraud and false claims.
Our lawyers defend doctors and clinics, dermatologists, chiropractors, home healthcare providers, and durable medical equipment suppliers charged with healthcare fraud and conspiracy to commit fraud.
Conspiracy To Provide Unnecessary Services
State and federal investigators have, in recent years, increased their efforts to uncover healthcare fraud. In certain cases, overzealous investigators who don’t always understand the intricacies of billing or the practical realities of treating patients, mistakenly assume that irregularities point to fraud.
Due to the complexity and confusing nature of medical billing, the wrong code can be used over and over again for different procedures or classification of care. When state or federal investigators review billing records, a simple mistake can look like a pattern of behavior indicative of fraud. Alternatively, mistakes in diagnostic billing codes can appear to be repeat or unnecessary healthcare services if an investigator doesn’t understand what happened at the point of service in the doctor’s office.
What Causes an Audit?
In most cases, it all begins with a civil audit of questionable billing practices. This can be triggered by a variety of state or federal agencies, often in concert with private insurance industry organizations dedicated to exposing healthcare fraud:
- Medicaid/Medicare fraud investigation units in each state, reporting to the state Attorney General’s office
- The Centers for Medicare and Medicaid Services, the division of the federal Department of Health and Human Services overseeing the agencies in each state
- The National Healthcare Anti-Fraud Association
- The National Insurance Crime Bureau
- The Blue Cross/Blue Shield Bureau
While these agencies use sophisticated programs to identify billing patterns and use of ICD-9 and CPT codes, they often reach the wrong conclusions. As Medicaid and Medicare audit defense lawyers, we conduct our own investigation — meeting with providers and employees, reviewing documents and billing codes, and interviewing potential witnesses.
Very often, ambiguities in the classification of procedures or billing codes for services are interpreted one way by providers and construed another way by civil auditors. We use every resource to demonstrate a lack of criminal intent and convince auditors that our clients were trying to comply with a complex and ever-changing system.
