Medicaid Fraud Defense for Hospice Businesses

Experienced Defense Counsel for Hospice Businesses Facing Allegations of Healthcare Fraud Under Medicaid

Hospice providers play an essential role in our nation’s healthcare system. Even so, they have come under intensive scrutiny in recent years, with federal authorities targeting hospice businesses suspected of submitting fraudulent claims under Medicaid and other federal healthcare programs.

Facing allegations of Medicaid or Medicare fraud is a very serious matter. These allegations can lead to civil or criminal liability—and a criminal indictment can potentially lead to federal prison time. As a result, for hospice businesses that are facing federal scrutiny, executing an informed and proactive defense strategy is essential.

Understanding What Constitutes “Hospice Fraud” Under Medicaid

Allegations of hospice fraud can take many different forms. Federal authorities pursue hospice fraud allegations under the False Claims Act, and False Claims Act violations can carry civil or criminal penalties depending on the circumstances involved. With this in mind, some examples of common allegations against hospice businesses (and their owners) include:

Phantom Billing – Billing Medicaid for hospice services that were not actually provided (including services allegedly provided to “ghost patients”)
Coding Errors – Upcoding, unbundling, and other intentional or unintentional Medicaid coding mistakes
Lack of Medical Necessity – Improperly certified or re-certified medical necessity used to justify fraudulent Medicaid billings
Ineligible Services or Patients – Billing Medicaid for ineligible services or for services provided to ineligible patients
Forced Enrollment – Enrolling patients for hospice services without their (or their family’s) knowledge or consent
Improper Retention of Overpayments – Failing to return known overpayments from Medicaid
Anti-Kickback Statute and Stark Law Violations – Offering improper payments to (or accepting improper payments from) another healthcare organization in exchange for patient referrals

As noted above, healthcare fraud cases involving these (and other) allegations can lead to serious consequences. While most Medicaid fraud cases are civil in nature, healthcare audits and government investigations can lead to criminal charges against healthcare providers in some cases. With this in mind, if your hospice company is facing scrutiny related to its Medicaid billings (or any other alleged fraud scheme), it is imperative that you engage experienced defense counsel promptly.

Hospice Fraud Cases Can Expose Businesses and Their Owners to Civil or Criminal Penalties

Given the substantial risks involved in facing Medicaid-related scrutiny, it is worth taking a closer look at the penalties that could be on the table. If auditors, federal agents, or federal prosecutors are looking into your hospice business’s Medicaid billings, this could present risks including:

Recoupments and treble damages
Pre-payment review
Civil fines
Denial of pending claims
Other civil penalties (i.e., Medicaid exclusion)
Criminal fines
Federal prison time

With this in mind, if your business is facing allegations of suspected hospice fraud under federal law, engaging experienced defense counsel will be critical for avoiding serious hospice fraud charges or other serious charges for health care fraud. With a defense team that includes former federal prosecutors, we have the experience required to defend your hospice business, palliative care organization, or healthcare conglomerate, and we can get to work immediately if necessary.

We Defend Hospice Businesses During Medicaid Audits and Billing Fraud Investigations

We handle Medicaid audits and billing fraud investigations targeting all types of healthcare service businesses within the hospice care system. If your business is facing an audit or federal investigation involving any of the following, we can dispute any allegations of criminal intent and target a favorable resolution that protects your ability to submit future claims to Medicaid:

Audit contractors working with the Centers for Medicare and Medicaid Services (CMS)
Federal Bureau of Investigation (FBI)
Internal Revenue Service (IRS)
Medicaid Fraud Control Units (MFCUs)
U.S. Department of Health and Human Services Office of Inspector General (HHS OIG)
U.S. Department of Justice (DOJ)
U.S. Drug Enforcement Administration (DEA)

Along with Medicaid audits and billing fraud investigations, within our national hospice defense practice, we handle Medicare audits, investigations targeting alleged improper Medicare payments, allegations of Tricare fraud, and other fraud-related allegations as well. Some examples of our relevant experience include:

Successfully defending a healthcare service business investigated for fraud
Successfully defending a healthcare marketing group investigated for fraud
Successfully defending a large healthcare organization investigated for fraud
Successfully defending a major healthcare conglomerate investigated for fraud
Successfully defending a physician syndication investigated for fraud

Our clients range from small hospice businesses to entire healthcare systems, and we routinely represent clients in high-stakes billing audits and criminal government investigations. We provide corporate compliance services as well; and, when our clients are facing scrutiny, we assist them with conducting internal investigations focused on comprehensively assessing compliance. Knowing what (if anything) auditors or investigators are going to find is critical for developing and executing an informed defense strategy.

From New York to Los Angeles, We Handle Hospice Care Fraud Cases Nationwide

From New York to Los Angeles, our lawyers represent clients in hospice care fraud cases nationwide. In these cases, we provide legal services including (but not limited to):

Internal Investigations and Risk Assessments

As we just mentioned, when facing Medicaid-related scrutiny, conducting an internal investigation (or internal risk assessment) is a key first step toward making informed decisions.

Defense Strategy Formulation

Once we have a clear understanding of the allegations that could be forthcoming, then we can formulate a defense strategy that is tailored to the specific circumstances (and risks) at hand.

Direct Communication with Auditors or Federal Authorities

Throughout the process, our lawyers will communicate directly with auditors or the relevant federal authorities on your behalf—gaining insight into the inquiry and helping prevent overreach.

Targeting a Favorable Resolution that Preserves Medicaid Eligibility

Regardless of the circumstances at hand, we will target a favorable resolution that not only avoids unnecessary financial liability, but that also preserves your hospice business’s Medicaid eligibility.

Medicaid Billing Compliance Counseling for Hospice Businesses

We provide Medicaid billing compliance services as well; and, if desired, our lawyers can help you implement a custom-tailored compliance program that will help protect your business going forward.

FAQs: Facing Medicaid Billing Fraud Allegations Related to Hospice Care

Why is the federal government looking into my hospice business’s Medicaid billings?

The federal government may be looking into your hospice business’s Medicaid billings for several reasons. One possibility is that an auditor’s automated billing data analysis has revealed anomalies in your business’s program billings (though anomalies are not necessarily indicative of fraud). Another possibility is that a patient or competitor has filed a complaint with CMS or HHS OIG. There are other possibilities as well, and discerning why your business is facing scrutiny will be a key first step toward building an informed defense strategy.

What are the potential outcomes of a Medicaid hospice billing audit?

Broadly speaking, Medicaid hospice billing audits can have two potential outcomes: (i) they can result in a determination of compliance; or, (ii) they can result in allegations of Medicaid billing fraud. If auditors uncover evidence (or apparent evidence) of billing fraud, this can lead to liability for recoupments, treble damages, and civil fines, as well as prepayment review, denial of pending claims, and potentially even loss of Medicaid eligibility. Unfavorable audit determinations are subject to appeal, and hospices may be able to file appeals on various grounds.

What are the potential outcomes of a Medicaid hospice billing fraud investigation?

Medicaid hospice billing fraud investigations can be resolved without further consequences in some cases. In others, however, they can lead to serious civil or criminal charges.

Facing an investigation does not necessarily mean that your business has violated the law. When facing a Medicaid billing fraud investigation, building an effective defense strategy starts with gaining a clear understanding of the scope of the investigation and ensuring that you know what (if anything) investigators may find. We have extensive experience representing clients that are facing Medicaid-related scrutiny, and we can use our experience to intervene in the government’s investigation and execute a defense strategy that reflects the specific circumstances at hand.

What should I do if my hospice business is facing a Medicaid audit or billing fraud investigation?

If your hospice business is facing a Medicaid audit or billing fraud investigation, you should engage experienced defense counsel promptly. These are high-risk inquiries, and it will be important for you to rely on the advice and representation of a team of experienced attorneys who can help you work to avoid unnecessary consequences.

Do I need to engage a law firm for a Medicaid audit or billing fraud investigation?

Due to the substantial risks involved, when facing a Medicaid audit or billing fraud investigation, engaging a law firm to handle the inquiry is essential. You should choose a law firm that has specific experience representing clients in these types of cases.

Schedule a Free and Confidential Consultation with the Hospice Fraud Defense Lawyers at Oberheiden P.C.

Our lawyers have extensive experience representing hospice businesses and other clients in federal healthcare audits and investigations. To speak with one of our senior attorneys about your business’s legal needs in confidence as soon as possible, call 888-680-1745 or tell us how we can reach you online now.