Anaheim Federal Health Care Fraud Defense
Effective Anaheim Health Care Fraud Defense Attorneys Defending Medical Professionals and Industry Businesses
Whether you have learned that you are the target of a federal investigation or you have were notified about a federal indictment, your defense strategy could significantly impact your professional license, medical enterprise’s survival, your financial future, and even your freedom. Although the U.S. Department of Justice (DOJ) and other federal and state agencies have aggressively pursued “qui tam” actions and criminal prosecutions against health care providers for many years, these efforts have intensified against the backdrop of the opioid addiction crisis. Medical professionals practicing in Anaheim and throughout Southern California now face more threats to their career and reputation than arguably at any time in history.
About Oberheiden, P.C.
There are many exemplary law firms to represent you against the federal government. However, our uniquely chosen team of former DOJ prosecutors provide our clients with intimate knowledge of the tactics used by federal law enforcement agencies. This insider knowledge explains why so few of our clients targeted by a health care audit or grand jury investigation end up facing criminal or civil liability. The goal of Oberheiden, P.C. is not just to prevent a conviction but also to prevent our clients from falling under the cloud of federal charges in the first place.
Anaheim, California Area Health Care Professionals Embroiled in Massive Health Care Fraud Case
The federal crackdown on medical practices, physicians, pharmacies, nursing homes, and other individuals and businesses in the health care industry has already ensnared parties in Anaheim. A recent massive Department of Justice prosecution involving $1.3 billion in alleged false billings generated health care fraud allegations against over a hundred medical professionals and health industry businesses. Law enforcement authorities indicated the case was the largest health care fraud enforcement case by a Medicare Fraud Strike Force with over 400 people arrested. Seventeen individuals from California were charged with participating in schemes to defraud Medicare of $147 million including Orange County cities near Anaheim.
This investigation following in the wake of a media focus on financial abuses within California’s addiction treatment industry. An article by the Southern California News Group based on an investigation found “[t]he revolving door between detox centers, treatment facilities, sober living homes and, often, the streets generate huge money for opeators who know how to game the system.” The article claims lax regulatory practices has paved the way to Southern California being deemed “The Rehab Riviera.”
This health care fraud enforcement effort mirrors many across the U.S. because of the breadth of agencies and law enforcement authorities involved in investigations and prosecutions of Medicare fraud. Agencies that collaborated in this large health care fraud takedown included:
- IRS Criminal Investigations
- Department of Labor – Employee Benefits Security Administration
- Drug Enforcement Agency
- Department of Defense
- Department of Health and Human Services – Office of Inspector General
- Department of Justice
- United States Postal Service – Office of the Inspector General
While these agencies reflect the impact of the opioid abuse epidemic in attractiving virtually limitless resources of the federal government, state and local governments also have begun targeting health care professionals and entities for recoupment of increased public spending created by health care fraud involving the prescription and distribution of opioids like oxycontin.
Federal Anti-Kickback Statute, Stark Law & Fraud Defense in Anaheim
- Anti-Kickback Statute. Our Anaheim health care fraud defense lawyers provide legal advice and compliance evaluations to facilitate our clients’ compliance with the federal Anti-Kickback Statute (AKS) (42 U.S.C. 1320a-7b). Because of the experience of our former DOJ attorneys representing health care clients throughout the nation, we have extensive experience advising providers of medical services on avoiding violations of the AKS. This statute prohibits “knowingly and willingly” receiving or soliciting renumeration in any form for the referral of Medicare, Tricare or any other federal health care program. Violations of the AKS will be treated as a criminal offense carrying harsh penalties and jeopardizing the status of a party’s professional license.
The seasoned and dedicated Anaheim health care fraud defense attorneys at Oberheiden, P.C. have the experience to mount a persuasive defense based on your lack of the required intent under the statute. Alternatively, we might defend your actions based on your participation in a transaction or arrangement protected by the Safe Harbor regulations, which includes a bona fide employment relationship. We tenaciously defend our clients from this felony, which carries harsh penalties that include a $25,000 fine per violation, imprisonment for up to five years, or both.
Stark Law. The Stark law (42 U.S.C. 1395nn), referred to as the “Physician Self-Referral Prohibition,” is a complicated matrix of regulations that have consistently expanded since their creation in 1995. While the law once was narrowly limited to only clinical lab services, the regulations now extend to a broad range of services, collectively termed “Designated Health Services” (DHS). Almost any financial relationship between a physician and his or her family members an entity that bills or performs for DHS will be covered. If a physician is accused of making a prohibited referral, the penalties are harsh. The punishment can include:
- Denial or Refund of Payments
- Civil fine of $15,000 fine per service
- $100,000 civil penalty per improper relationship
Our team of former DOJ Health Care Fraud prosecutors can analyze whether your potential or existing relationship could run afoul of the Stark law. We also can analyze whether pending charges might be defended based on an exception under the law. If you are interested in a compliance plan, our lawyers have the expertise to assist you in structuring your agreements, policies, and procedures to avoid Stark violations.
- Criminal Health Care Fraud Statute. Federal prosecutors can pursue a conviction under this statute (18 U.S.C. 1347) for a scheme to intentionally (1) defraud a health care benefit program or (2) provide false statements to obtain benefits from such a program. The penalties under this criminal statute include a maximum 10 year term of imprisonment and a fine of up to $500,000 or double the amount of the value obtained through the fraud. Given the lengthy period of imprisonment permitted under this statute, any health care professional or business facing an investigation should seek immediate legal advice.
- False Claims Act. The False Claims Act (FCA) constitutes the federal government’s primary weapon for pursuing allegations of health care fraud. The statute prohibits the submission of a fradulent or false claim for payment to the federal government. The law also forbids making false statements in support of such a claim for payment. The risk of liability under such a statute rises because private citizens like alienated former employees can pursue massive whistleblower awards under the statute. Consequences of a violation are punishable by treble damages and specified civil penalties.
Frequently Asked Questions (FAQ) Regarding Federal Health Care Fraud Defense
The best course of action when facing a federal health care investigation, grand jury proceedings, or a federal indictment is to speak directly with an experienced federal crimianl defense lawyer. However, we have provided answers to frequently asked questions.
How can a physician or other health care professional or business defend against federal health care fraud allegations?
Our defense tactics in an insurance fraud case will be carefully tailored to the specific facts and circumstances. Many cases that involve allegations of “up charging” are determined based on subtle distinctions regarding the characterization of services and complex rules governing reimbursement under Medicare, and private health insurance. The process of proper characterization of services is an imprecise process that allows room for reasonable disputes.
The knowledge of our experienced federal fraud attorneys along with health care billing experts can analyze how the services at issue were characterized, as well as the information available to the person who made the characterization. This inquiry can reveal a defense, such as a situation where the staff member made the designation based on instruction during a training course. If the fraud allegations are based on billing for medical services that are not medically necessary, we carefully analyze treatment records often with the assistance of a medical expert.
What types of practices do federal prosecutors typically focus on in health care fraud cases?
While there are many activities that can become the focus of a civil or criminal action alleging health care fraud, some that we see include:
- Phantom Billing: Billing for services that are never actually performed
- Repeat Billing: Billing multiple times for the same medical procedure, medications, or supplies
- Upcoding: Submitting a bill for a more expensive service than the one actually provided
- Unnecessary Treatment: Providing medical services that are not medically justified
- Self-Referrals: Improper referral for a medical service to an entity in which the referer has a financial interest
- Cloning: Employing a program to copy from the file of a patient with comparable symptoms to create the appearance of a more extensive examination
- Duration in OR: Hospitals charging based on the “average” stay rather than actual time in the the OR
- Coding Errors: Entering the incorrect billing code for a service or procedure
Are federal health care fraud prosecutions common in Anaheim and Orange County?
Although many health care professionals assume that the probability of becoming the target of a health care audit, federal fraud investigation, or grand jury indictment is relatively low, the review of a few statistics provides a more accurate picture.
- The Medicare Fraud Strike Force commenced criminal prosecutions against 353 individuals during a recent 12-month period.
- The DOJ recovered over $2.5 billion in judgments and settlements in civil actions involving fraud and related false claims in the 2016 fiscal year from the health care industry.
- The DOJ also recovered over $2 billion during the preceding six consecutive years.
- Orange County and Southern California are among the most heaviest investigated areas of the United States.
Exemplary Federal Defense of Health Care Professionals & Businesses Facing Investigations and Audits
Whether you are a doctor or other entity in the health care industry, the threat of a Medicare, or a private insurance audit can disrupt your practice or business. Oberheiden, P.C. brings vast experience defending clients in all forms of health care audits. Our team of federal former prosecutors understand how to prepare for and defend against audits conducted by state law enforcement agencies, Recovery Zone Auditors, and Zone Program Integrity Contractors. We provide assistance with compliance issues to mitigate the risk of an audit and to lower the probability of errors that could be revealed during an audit. Medical providers and companies that implement an effective billing compliance plan can lower the risk of an unfavorable audit. Our law firm has a track record of guiding clients through audits without triggering civil or criminal health care fraud charges.
Auditors might conduct an offsite audit (referred to as a “desk audit”) or an onsite audit that might include several overpayment or fraud detection approaches. Examples include analyzing the targets claims against similar local providers or data mining performed by using statistical models to identify outliers. When a state auditor finds a basis for suspecting fraud, the case will be referred to the Medicaid Fraud Control Unit. Skilled and seasoned Anaheim health care fraud defense lawyers can assist you in avoiding massive overpayment demands, anti-kickback actions, and fraud claim charges.
Federal Defense in Medicare Fraud Cases
When a health care professional is accused of engaging in fraud, he or she can face civil or criminal charges for Medicare fraud. Time is of the essence in retaining legal representation because Medicare fraud cases progress rapidly and often result in devastating consequences. These cases frequently are assigned to special prosecutors with extensive experience in health care fraud matters.
Because we have several former DOJ attorneys who have collectively handled hundreds of DOJ health care fraud cases as prosecutors, our team is well-versed in overpayment actions, Medicare audits, and fraud detection. We have the expertise and skill to handle the most complicated Medicare fraud action.
When prosecutors contend a medical professional knowingly or willfully presented a false claim, received a kickback, or engaged in health care fraud, actual knowledge of the false claim is not required to obtain a conviction. Reckless disregard for the truth or willful ignorance can result in liability and severe sanctions. When our health care clients retain Oberheiden, P.C., they tip the scales of justice in their direction because we are one of the leading health care fraud defense law firms in the U.S. If you have learned that you are the target of a federal investigation or a grand jury indictment, our federal attorneys have represented clients in over 500 federal jury trials and thousands of grand jury proceedings.
Former DOJ Prosecutors Offer Decisive Federal Health Care Fraud Defense in Anaheim
Our Anaheim, CA health care fraud defense lawyers are committed to protecting the professional licenses of our clients while avoiding escalation of a health care audit or investigation to a federal grand jury proceeding. Whether you are facing the prospect of civil or criminal liability, our Orange County medical fraud defense attorneys tenaciously defend our clients’ reputation and future. We invite you to call us at (888) 519-4897 or request a free case evaluation online now, so we can discuss your situation and explain your options. Our law firm does not just defend clients against Medicare fraud charges. We also strive to minimize the impact the charges will have on the many facets of your professional practice or business.
Compliance – Litigation – Defense