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Dr. Nick Oberheiden

Lynette Byrd
Former Assistant
U.S. Attorney

How Can I Avoid Criminal Charges in a Medicaid Fraud Audit?

Categories: Health Care Law

medicaid audit gavel and money

The Current Reality of Medicaid Enforcement

Did your practice receive a request for patient charts? Are you under audit / ZPIC audit? Did a Medicaid intermediary send you a letter or did investigators from the Medicaid Fraud Control Unit tried to interview you? Are you concerned you could be under Medicaid investigation?

If so, this is what you need to know.

Few health care programs are as rigorously monitored and enforced as the Medicaid Program. Special task forces such as the Medicaid Fraud Control Unit (MFCU), the Federal Bureau of Investigation (FBI), and the Office of Inspector General (OIG) are working closely with the Attorney General’s Office and the Department of Justice to audit, monitor, and investigate potential fraud occurrences.

Dentists, pediatric dentists, and physicians (in particular family practice and pain management physicians) are among the most heavily scrutinized Medicaid providers. What often starts with a simple request for patient charts can quickly get out of control — if you don’t engage experienced counsel early to intervene on your behalf.

When reading the news about health care crackdowns, waves of arrests against medical providers, and reports about indictments in the health care industry, the truth is that every provider must be on alert to do things right (or to fix things the right way, right away!). This applies all the more to those providers that contracted with CMS, Medicaid and Medicare, and are thus subject to aggressive federal law enforcement.

If your practice is subject to a Medicaid audit, read this article. Most importantly, don’t make the number one mistake, the one mistake that no lawyer in the world can undo: that is to handle your Medicaid issues yourself.

Meet Medicaid Defense Attorney: Dr. Nick Oberheiden

Attorney Dr. Nick Oberheiden has a long and proven track record of favorably resolving Medicaid audits and investigations. To date, not a single client that contacted Nick with a Medicaid or Medicare audit was ever referred to the U.S. Attorney’s Office or otherwise referred to criminal prosecution. In fact, every single provider that contacted Nick Oberheiden in connection with a health care audit kept his or her license, regardless of the error rate in the patient charts and regardless of how much information (e.g. medical notes, X-Ray pictures or reports etc.) were missing or unavailable at the time of the audit. Here are some examples.

  • Representation of Medicaid Provider (Dentist, Washington D.C.): The Office of Inspector General (OIG) and the Department of Health and Human Services (HHS) subpoenaed approximately 40 patient files from the client. In conversations with the government agents and lawyers it became quickly clear that the investigation had a criminal component. Our client had a malpractice and disciplinary history, including temporary license suspensions. The allegations made by the government were long and very concerning and included among others medical necessity, malpractice, and billing for services not rendered. The government’s expert, hired by the Department of Health and Human Services (HHS) called our client’s hygiene and quality of service among “the worst ever seen in more than 30 years of serving as an expert witness.” Despite these challenges, every single client goal was met: we avoided criminal prosecution; we also avoided a referral to the U.S. Attorney’s Office for civil prosecution; further, the government waived its right to report the client to the state licensing board; finally, the client settled the case with the government for approximately 15% of the original government demand. Mission accomplished!
  • Representation of Medicaid Provider (Physician/Chiropractor): Every audit comes as a shock and this client was no exception. The government intermediary made a request for six patient files. However, due to some inaccuracies and some lack of oversight, four of the six files were incomplete and were missing critical documentation that would substantiate and justify the billed procedure. Nick Oberheiden initiated a line of communication with the auditor and introduced a number of valid and applicable reasons for the chart situation. The audit concluded with no civil and no criminal liability for our client. The client maintained all CMS privileges.
  • Representation of Medicaid Provider (Pain Management): Client contacted Nick Oberheiden regarding a pressing Medicaid issue. The United States government requested four patient files from the client within a short deadline. Needless to say, the files were problematic. Nick contacted the government and, while securing a two-week extension to locate and produce the records, Nick began discussing the overall purpose of the audit and ways to resolve the investigation. Together with his team, he convinced the government to rescind the subpoena and to withdraw the request for files.
  • Representation of Medicaid Provider (Dentist): Nick Oberheiden was called to action by a Medicaid provider that was under audit and attack by Medicaid. After a diligent assessment, Nick took a number of measures to boost compliance at the clinic, trained the staff, incorporated relevant policies, and then reached out to the auditor. Although the audit concluded that a number of records were missing, some billed services were not performed, and medical necessity was denied with respect to several expensive procedures, Nick Oberheiden was able to settle this complex audit for less than eight hundred (800) dollars in settlement fees.

Unlike the practice of other lawyers, representing medical providers is not just a hobby. That’s all Nick Oberheiden and his team do. With that focus comes experience and with experience comes the priceless ability to achieve the client’s stated goals in each case. If you are subject to an audit, if you are afraid of losing your medical license, you simply can’t afford to experiment. Call Nick right away. Let’s discuss your situation and let’s make sure you can sleep again.

There Are No Perfect Audits, and Here Is Why

Few people decide to systematically and deliberately and continuously rob Medicaid. Instead, the vast majority of medical providers report that the sheer volume of patients, the workload, the complexity of billing codes, and unreliable staff members contribute to file imperfection. It is hard to be a good doctor, a good businessman, and a good administrator, all at the same time. Do any of the following reasons happen to explain why patient files in your office may contain some errors as well?

  • Transition from Paper to Electronic Records
  • Office Moving or Corporate Changes in Ownership
  • Unqualified Administrative Staff
  • Theft of Charts by Former Employee
  • Lack of Corporate Organization Due to Workload
  • Many More…

The important thing about these explanations is to convey and discuss them with the auditing entity. In virtually all cases that we inherit from other law firms we see the classic pattern of a defense attorney, that is, sit back and wait for the government to make a move and then defend the case. Nick Oberheiden’s approach is radically different and radically more successful. From the moment he takes on an audit, he engages with the government or insurance company with the view of getting the case resolved. See, from the perspective of an auditor, who receives a few dozens of new audit cases every week, nothing can be more appealing than having a communicator as the physician’s representative who understands and respects the auditor’s job while, at the same time, will make the auditor’s job as easy and smooth as possible by being available to competently answer questions and discuss matters as they arise in the auditing process.

Speak to a Real Attorney Right Away: Free & Confidential

When you call Nick Oberheiden, you will speak to Nick Oberheiden; not to his secretary, not to a paralegal that tries to give you some half-true legal advice over the phone. Unless in court or with clients, Nick will answer the phone right away or call you back if you leave a message. Promised and guaranteed. Call today and get competent answers right away.

FAQs: What Can Happen in a Medicaid Compliance Audit?

Q: My Situation Is Very Bad: Can You Still Help?

Absolutely. As some of the examples above have shown, there are no hopeless cases. What does make cases difficult are hesitation and delay. The longer you wait and the more time passes without effective counsel’s intervention, the more difficult it is for us to undo mistakes or to regain credibility. That said, from the moment you become aware of issues with respect to your billing practice or operations, you should recognize the advantages of being represented by experienced counsel. Attorney Nick Oberheiden has helped many providers navigate through audits, including very tough ones, and he is happy to do the same for you. All that is required is you reaching out to him so that he can take control of the situation.

Q: I am Under Audit and Some of My Files Are Missing: What Should I Do?

Perfect files are rare. The complexity of running a medical practice and a business at the same time inevitably leads to mistakes, in particular when important administrative tasks are delegated to office staff, outside vendors, or unqualified billing personnel. The most important thing NOT to do is to fabricate or manipulate the file when an audit request comes in. The file is what the file is. Don’t retrospectively add notes, supplement documents, or rewrite information. It’s a short-sighted strategy that typically results in great problems. Auditors will often compare the originally submitted billing documents with the documents provided in the audit process. Any discrepancy would inevitably create a significant risk of criminal prosecution, and, at an absolute minimum, you failing the audit.

Q: What Are the Chances that My Audit Results in Criminal Charges?

Nick Oberheiden is one of the most sought after health care fraud defense attorneys who regularly advises and defends clients in health care fraud cases. That “front experience” is very valuable with respect to health care audits. Understanding what constitutes a real criminal case and seeing on a routine basis how criminal cases have unnecessarily developed out of poorly handled audits helps to assess the true exposure in each case and it helps to avoid making the mistakes of others that have turned routine audits into referrals to the U.S. Attorney’s Office. To date, not a single client that trusted Nick with his or her health care audit resulted in a referral for civil or criminal prosecution.

Why Do Medicaid Providers Trust Dr. Nick Oberheiden, Esq.?

Medicaid providers trust attorney Nick Oberheiden because he knows how to successfully guide his clients through even the toughest audits and investigations. Nick has a long history of avoiding criminal charges in health care audits and investigations — and he is ready to do the same for you! Contact him today online, or call (800) 810-0259.

Oberheiden, P.C.
Compliance – Litigation – Defense
National Service
(800) 810-0259
(214) 469-9009

Who Will Handle Your Case

When you hire us, you will not work with paralegals or junior lawyers. Each lawyer in our Health Care Practice Group has handled at least one hundred (100) matters in the health care industry. So, when you call, you can expect a lawyer that immediately connects with your concerns and who brings in a wealth of experience and competence.

Dr. Nick Oberheiden

Dr. Nick

Lynette S. Byrd

Lynette S.