Fresno Healthcare Fraud Defense Lawyer
Our Fresno healthcare fraud defense attorney brings decades of experience to representing individual providers, company executives, and healthcare organizations in federal investigations. If your Fresno, CA, business or practice is under investigation, call 888-680-1745 for a free consultation.
If you are like most licensed medical professionals or company executives, you never thought much about the risk of being targeted in a federal investigation. You understood the burdens of complying with federal healthcare program billing regulations and the conditions for registration with the Drug Enforcement Administration (DEA), and you believed that your compliance efforts would be enough to allow you to avoid federal scrutiny.
So, now that you have the government’s attention, what should you do? How can you prove that your business or practice has consistently remained fully compliant? Or, if there are issues, how can you address them in a way that allows you to avoid civil or criminal prosecution? These are not easy questions to answer. To protect your healthcare business or practice, you will need experienced legal representation.
A Fresno healthcare fraud defense attorney in Oberheiden, P.C. represents individual and business clients in healthcare fraud investigations in Fresno, CA. Our team is comprised entirely of senior defense attorneys and former federal prosecutors who have centuries of combined experience on both sides of federal investigations. If you are under investigation, you have options available. But choosing the best option for defending your business or practice requires knowledge and insights that can only be acquired by personally handling thousands of federal cases.
In-Depth Knowledge and Strategic Insights for Healthcare Fraud Investigations in Fresno
What does it mean to be under investigation for “healthcare fraud”? This is a surprisingly complicated question, and there is not one single answer that will apply to all providers in all cases. Healthcare fraud is an umbrella term that covers a variety of different types of offenses (including offenses that are civil and criminal in nature), and federal healthcare fraud investigations will often involve allegations under multiple civil and criminal laws.
As a result, when defending against a federal healthcare fraud investigation, one of the first steps is to determine exactly what you need to defend against. In order to identify the allegations against our clients, we intervene in the government’s investigation with the goal of quickly acquiring some key pieces of information:
- Which federal agency (or agencies) are handling the investigation?
- Is the investigation civil or criminal in nature?
- What triggered the investigation (e.g., automated comparative analysis of billing data or a “whistleblower” complaint)?
- How long has the investigation been ongoing?
- What types of information are the investigating agencies seeking to collect?
Once we ascertain the answers to these questions, we can then discern the allegations underlying the government’s decision to target our client, We can then execute a defense strategy that is custom-tailored to the particular facts, circumstances, laws, and regulations involved. In most cases, this means defending against allegations such as:
- Billing for medically-unnecessary services
- Billing for services not actually rendered to patients
- Controlled Substances Act and DEA registration violations (e.g., prescription drug fraud)
- Department of Labor (DOL) fraud
- Falsifying patient records, prescriptions, physician certifications, and election statements
- Medicare, Medicaid, and Tricare fraud
- Stark Law violations (physician “self-referrals”)
- Unlawful kickbacks and referral fees (Anti-Kickback Statute violations)
In any case, prompt intervention and a proactive defense are the keys to avoiding costly prosecution and civil or criminal penalties. To start protecting yourself, your employees, and your business or practice in Fresno, call us at 888-680-1745 now.
What Practitioners and Business Owners in Fresno, CA, Need to Know about Federal Healthcare Fraud Investigations
1. The False Claims Act
The False Claims Act (FCA) applies to all healthcare providers and businesses that bill federal benefit programs (i.e., Medicare, Medicaid, Tricare, and DOL) for reimbursement. It outlaws all “false and fraudulent” claims, and it imposes criminal penalties (including fines and imprisonment) for intentional billing violations.
Under the FCA, the standard for “fraud” is much lower than most people think. In order to be exposed to civil penalties (which include recoupments, assessments, fines, and program exclusion), it is enough if you should have known about the submission of any claim that was non-compliant with the applicable set of program billing regulations.
2. The Anti-Kickback Statute
The Anti-Kickback Statute (AKS) prohibits healthcare providers and other businesses (including durable medical equipment (DME) manufacturers and pharmaceutical companies) from offering, paying, soliciting, or receiving any form of “remuneration” in exchange for a referral for services, supplies, or equipment to be provided to a federal healthcare program beneficiary. This includes not only referral fees and other direct financial incentives, but also meals, entertainment, travel, and other in-kind gifts of any value.
While there are a number of potential defenses to allegations under the AKS, one of the most effective defense strategies in many cases is to demonstrate that one of the statute’s “safe harbor” provisions applies.
3. The Stark Law
The Stark Law imposes civil penalties for physician self-referrals. A “self-referral” is any referral for Medicare or Medicaid reimbursed services that is provided to an entity with which the referring physician has a financial relationship. Referrals flowing in the opposite direction can trigger Stark Law liability for both parties to the transaction as well.
The Stark Law’s prohibitions only apply to “designated health services.” These include:
- Clinical laboratory services
- Physical therapy services
- Occupational therapy services
- Outpatient speech-language pathology services
- Radiology and certain other imaging services
- Radiation therapy services and supplies
- Durable medical equipment and supplies
- Parenteral and enteral nutrients, equipment, and supplies
- Prosthetics, orthotics, and prosthetic devices and supplies
- Home health services
- Outpatient prescription drugs
- Inpatient and outpatient hospital services
4. The Controlled Substances Act
The Controlled Substances Act is one of the primary federal statutes used to prosecute providers suspected of prescription drug-related offenses. Investigations under the Controlled Substances Act typically involve the Drug Enforcement Administration (DEA), and they often involve allegations that carry the potential for huge fines and long-term imprisonment.
5. The Federal Healthcare Fraud Statute
The healthcare fraud statute, 18 U.S.C. 1347, makes it a federal offense to “knowingly and willfully execute, or attempt to execute, a scheme . . . to defraud any healthcare benefit program . . . [or to obtain] money or property owned by, or under the custody or control of, any healthcare benefit program [by false pretenses].” While most violations of 18 U.S.C. 1347 carry a maximum prison sentence of 10 years, violations resulting in serious bodily injury carry a maximum sentence of 20 years.
6. Conspiracy, Attempt, and Other Related Criminal Offenses
In criminal healthcare fraud investigations, providers can face charges under multiple other federal statutes as well. In fact, even if a provider is found not to have committed a fraudulent offense, that provider can still face fines and imprisonment for conspiracy or attempt. Other statutes that commonly come into play in federal healthcare fraud investigations include:
- 18 U.S.C. 371 (criminal conspiracy)
- 18 U.S.C. 1028A (identity theft)
- 18 U.S.C. 1341 (mail fraud)
- 18 U.S.C. 1343 (wire fraud)
- 18 U.S.C. 1344 (bank fraud)
- 18 U.S.C. 1357 (money laundering)
- 21 U.S.C. 841 (distribution of controlled substances)
- 26 U.S.C. 7206 (tax fraud)
7. Program Billing Regulations
As we mentioned earlier, violations of healthcare program billing regulations can trigger liability under the False Claims Act. Billing and coding violations can trigger Anti-Kickback Statute, Stark Law, and healthcare fraud statute investigations as well, and providers accused of submitting multiple improper reimbursement requests can face insurmountable financial penalties. We have experience in cases involving thousands of alleged improper billings with each individual reimbursement claim carrying the potential for tens of thousands of dollars in fines and assessments.
8. DOJ Mandates
While all forms of healthcare fraud can (and do) trigger federal investigations, the U.S. Department of Justice (DOJ) has recently identified prescription opioid diversion as a top federal law enforcement priority. The DOJ has established multi-agency task forces in California and around the country, and these task forces are closely examining providers’ prescription practices. As a result, any complaints or other evidence of opioid diversion are likely to trigger a swift and high-stakes investigation.
Frequently Asked Questions
What are some examples of healthcare fraud?
Healthcare fraud refers to any falsified claim for reimbursement submitted to a federally funded program, such as Medicare, Medicaid or Tricare. In a typical arrangement, healthcare providers render services or supplies to a patient and then submit a form for reimbursement. Given the vast number of claims filed, it may seem as though the federal government doesn’t keep a close eye on these submissions. However, that is not the case. There are several agencies charged with investigating healthcare fraud, and investigators can pick up on even small or isolated instances of misconduct. Below are some of the most common reasons the government will choose to pursue healthcare fraud charges:
- Billing for services that were not performed
- Billing for services that were not medically necessary
- Billing for supplies or equipment that were never ordered
- Billing for supplies or equipment that were not medically necessary
- Certification for services or supplies that were not medically necessary
- Double billing, up-coding, and inflating bills
- Overutilization of services or equipment
If you are involved in a healthcare audit or investigation, reach out to a Fresno federal healthcare fraud defense attorney immediately.
What is the False Claims Act?
The False Claims Act is a federal statute that prohibits anyone from submitting a false or fraudulent claim for reimbursement to a federal program. While some investigations under the False Claims Act stem from government investigations, many are the result of a whistleblower’s allegations. Punishments for a violation of the False Claims Act can carry both civil and criminal penalties, depending on the nature of the violation. If you face allegations that your practice ran afoul of the False Claims Act, it is imperative that you reach out to a Fresno, CA federal healthcare fraud defense attorney as soon as possible.
Who Investigates DEA Opioid Cases in Fresno, California?
Fresno is one of the hotspots of DEA opioid investigations. Pursuant to instructions from Washington D.C., federal prosecutors and DEA Diversion Investigators in California have begun to systematically scrutinize physician offices in California to identify the main prescribers of opioids, benzodiazepines, stimulants, sedatives, and muscle relaxants. The DEA is assisted by the Department of Justice, the U.S. Attorney’s Office, the Office of Inspector General, the Department of Health and Human Services, and the FBI.
5 Reasons to Choose the Fresno Healthcare Fraud Defense Lawyers at Oberheiden, P.C.
Why do healthcare providers in Fresno, CA, and nationwide trust Oberheiden, P.C.’s federal healthcare fraud defense team?
- We have a long record of achieving favorable outcomes in healthcare fraud investigations.
- We emphasize early resolution but do not hesitate to fight for our clients at trial.
- We rely on knowledge and insights from over 1,000 investigations and many trials.
- We provide direct access to our senior attorneys, and we do not employ junior associates or paralegals.
- We fight strategically, aggressively, and relentlessly to secure favorable outcomes for our clients.
Contact Our Fresno Healthcare Fraud Defense Attorneys for a Free and Confidential Consultation
If you need legal representation for a federal healthcare fraud investigation in Fresno, contact our Fresno healthcare fraud defense lawyer now to schedule a free initial consultation. To discuss your case in confidence, call 888-680-1745 or tell us how to reach you online now.