Health care providers accused of improperly billing Medicare can face steep fines and other penalties. Our team of senior defense attorneys brings centuries of combined legal experience to defending Arkansas health care providers in Medicare fraud matters.
The federal Medicare system serves an essential role in modern medicine. Not only does it provide patients with critical access to medical care, but it also allows health care providers to maintain financial stability while treating patients who do not have access to private health insurance. Each year, Medicare pays billions of dollars to health care providers, and program beneficiaries receive access to countless procedures and other forms of treatment that would otherwise be inaccessible.
However, as a result of its size, the federal Medicare system is also highly susceptible to fraud. Waste due to Medicare fraud and abuse also rises into the billions of dollars annually; and, as a result of this issue, multiple federal agencies devote substantial resources to targeting health care providers suspected of submitting fraudulent billings. While this means that many fraudulent health care providers get caught, it also means that legitimate and law-abiding providers can find themselves facing intensive and potentially-dangerous federal Medicare fraud investigations.
At Oberheiden, P.C., we represent health care providers in Arkansas and nationwide in high-stakes Medicare fraud matters. Our attorneys have centuries of combined experience on both sides of investigations and prosecutions, and we have a substantial track record of protecting clients against Medicare fraud charges. With the potential for civil and criminal penalties, health care providers targeted for Medicare fraud investigations must take proactive measures to defend themselves effectively, and this starts with engaging highly-experienced defense representation.
Federal Agencies that Investigate and Prosecute Health Care Providers Suspected of Medicare Fraud
Due to the scope of the nation’s Medicare fraud problem and the fact that allegations of Medicare fraud can trigger civil and criminal penalties under a multitude of federal statutes, there are several agencies that can potentially be involved in Medicare fraud investigations. At Oberheiden, P.C., we routinely represent health care providers in investigations involving:
1. Centers for Medicare and Medicaid Services (CMS)
The Centers for Medicare and Medicaid Services (CMS) are responsible for administration of the federal Medicare program. CMS routinely conducts investigations into participating providers’ billing practices, and it also works with fee-for-service contractors (such as ZPICs, RAC, and MACs) that audit participating providers’ Medicare billings.
2. Department of Justice (DOJ)
The Department of Justice (DOJ) is the top federal law enforcement agency. It investigates and prosecutes health care providers independently, and also works collaboratively with other agencies through joint efforts such as the Medicare Fraud Strike Force.
3. Department of Health and Human Services Office of Inspector General (OIG)
The Office of Inspector General (OIG) has broad investigative powers for targeting health care providers in civil and criminal Medicare fraud cases. Health care providers that receive civil investigative demands, target letters, and subpoenas from the OIG must swiftly take appropriate measures to defend themselves effectively.
4. Federal Bureau of Investigation (FBI)
The Federal Bureau of Investigation (FBI) routinely works with the DOJ, OIG, and other agencies in federal Medicare fraud investigations. The FBI has broad jurisdiction in federal matters; and, like other agencies, it has field offices in Arkansas and other states nationwide.
5. Internal Revenue Service (IRS)
The Internal Revenue Service (IRS) gets involved in Medicare fraud investigations that involve allegations of tax evasion and other tax crimes. Health care providers accused of intentionally overbilling Medicare will often face allegations of failing to report income to the IRS as well.
Billing Mistakes and Other Issues that Can Trigger Prosecution for Medicare Fraud
So, what exactly is “Medicare fraud”? The term “Medicare fraud” refers to a broad range of billing violations – both intentional and unintentional – that trigger civil or criminal penalties under the False Claims Act, the federal health care fraud statute (18 U.S.C. § 1347), and various other federal laws. Although every investigation involves unique elements related to individual providers’ billing practices and the specific billings in question, common allegations in Medicare fraud investigations include:
- Billing for services not provided
- Billing for services that were not “medically necessary”
- Billing for services at a higher rate than the one allowed (referred to as “upcoding”)
- Billing for related services and supplies at individual rates (referred to as “unbundling”)
- Double-billing for services, equipment, or supplies
- Inflating charges, mischaracterizing patient services, and making unnecessary use of medical equipment
- Paying illegal referral fees, rebates, or kickbacks out of Medicare-reimbursed funds
Civil and Criminal Penalties for Medicare Fraud
Depending upon the specific allegations involved, health care providers targeted for alleged Medicare fraud can face civil or criminal penalties. While the specific penalties under the False Claims Act, the federal health care fraud statute, and other relevant federal statutes vary, the types of penalties that are on the table in Medicare fraud cases include:
Civil Medicare Fraud Penalties
- Recoupment of overbilled amounts
- Denial of pending claims
- Pre-payment review of future claims
- Civil fines
- Treble (triple) damages
- Attorneys’ fees
- Exclusion from Medicare participation
Criminal Medicare Fraud Penalties
- Criminal fines
- Federal imprisonment (including the potential for life imprisonment in cases where fraudulent Medicare practices result in a patient’s death)
- Exclusion from Medicare participation and other program-related penalties
Licensed health care providers (such as physicians, physician assistants, pharmacists, and registered nurses) can face state licensing board action as a result of civil and criminal Medicare fraud investigations as well. This is true even if the investigation does not ultimately lead to federal charges.
Defense Strategies in Medicare Fraud Investigations, Grand Jury Proceedings and Trials
When we represent Arkansas health care providers in Medicare fraud investigations, grand jury proceedings, and civil and criminal prosecutions, we rely on various defenses and case strategies which we custom-tailor to the particular circumstances at hand. When you sit down with members of our federal health care fraud defense team, we will determine the availability of potential defenses and strategies such as:
1. Aggressive Intervention in the Government’s Investigation
If you are currently under investigation, aggressive intervention can slow down the investigation, help ensure that the investigation remains civil in nature, and provide our attorneys with the information they need to develop and execute a tailored defense.
2. Challenging Evidence of Billing Violations and Intent
It is not unusual for Medicare fraud investigations to be misguided. If possible, our attorneys will seek to demonstrate that your program billing practices are fully-compliant with federal law. If there is a chance that federal prosecutors might try to pursue criminal charges, we will vigorously dispute the government’s evidence of intent in order to try to keep your case civil in nature.
3. Asserting Constitutional Defenses
The constitutional protections against unreasonable searches and seizures, self-incrimination, and fair prosecution can provide strong defenses even in cases where the government’s allegations cannot fully be rebutted.
4. Asserting Affirmative Defenses
Affirmative defenses such as the safe-harbors under the Anti-Kickback Statute and the Stark Law will protect health care providers in many cases as well.
5. Relentless Defense at All Stages of Prosecution
From investigation and indictment through pre-trial procedures, trial, sentencing, and appeal, by relentlessly defending our clients at every stage of the process, we maximize our chances of securing a favorable result that protects our clients’ ability to practice medicine and conduct business in Arkansas.
Potential Outcomes of Federal Medicare Fraud Investigations
Utilizing these and other defense strategies, our federal health care fraud defense team has succeeded in securing favorable results for the vast majority of our clients. This includes results such as:
- Avoiding civil or criminal charges
- Obtaining dismissal of charges prior to trial
- Negotiating civil penalties with no criminal plea
- Reducing felony charges to misdemeanors
- Avoiding federal imprisonment
Considerations for Choosing a Federal Medicare Fraud Defense Attorney
In order to mitigate the consequences of your CMS, DOJ, FBI, OIG, or IRS investigation, it is imperative that you seek legal representation as soon as possible. When choosing your defense team, it is important to consider factors such as:
- Experience – How many Medicare fraud investigations has the firm handled?
- Government Insight – Have any of the firm’s attorneys previously served as federal health care fraud prosecutors?
- Focus – Does the firm focus on federal defense, or do its attorneys handle cases in a broad range of unrelated practice areas?
- Trial–Readiness – Are the firm’s attorneys experienced litigators who have extensive trial records in federal district court?
- Team Approach – Will you be represented by a single attorney, or will you have a team of attorneys with centuries of combined legal experience on your side?
Meet the federal health care fraud defense team at Oberheiden, P.C.
Schedule a Confidential Case Assessment at Oberheiden, P.C.
If your medical practice’s or health care business’s Medicare billings are being scrutinized by federal authorities, of if you personally are facing charges for Medicare fraud in Arkansas, we encourage you to contact us immediately for a confidential case assessment. To speak with a member of our federal health care fraud defense team as soon as possible, please call 888-519-4897 or request an appointment online now.