Columbus Health Care Fraud Defense
Proven Columbus Health Care Fraud Defense Lawyers
Following a national takedown involving two providers in Central Ohio last year, federal prosecutors are continuing to aggressively target health care providers in Columbus. If your business or practice is under investigation, our health care fraud defense team can help protect you against severe penalties, including crippling fines and federal incarceration.
In July 2017, the U.S. Department of Justice (DOJ) announced the nation’s largest-ever health care fraud takedown. Involving law enforcement efforts in 41 federal districts, the takedown ensnared 412 defendants, including 115 “doctors, nurses, and other licensed medical professionals” who were allegedly part of a $1.3 billion fraud scheme that involved improper treatment and prescription of opioid medications.
Four of these defendants were based in Central Ohio. These individuals, who are collectively accused of defrauding Medicare and Medicaid out of more than $5 million, were charged with crimes carrying the potential for millions of dollars in fines and recoupments and decades of federal imprisonment. According to a Special Agent in Charge (SAC) with the Department of Health and Human Services’ Office of Inspector General (OIG):
“The charges announced today should send a strong message to criminals that theft from vital health care programs will not be tolerated. . . . The OIG and our law enforcement partners will continue to be vigilant in our efforts to protect taxpayer dollars that are intended to aid our most vulnerable citizens.”
In other words, health care providers in Columbus have cause for concern when it comes to being at risk for federal investigation and prosecution. Now that the federal government’s investigative efforts have led to local indictments, providers throughout Central Ohio may face enhanced scrutiny as the DOJ, OIG, Medicare Fraud Strike Force, and other federal authorities continue their fight against health care fraud and abuse.
Former DOJ Prosecutors Representing Health Care Providers in Columbus, OH
Oberheiden, P.C. is a health care fraud defense law firm that represents providers in Medicare, Medicaid, Tricare, and other health care benefit program fraud investigations. With attorneys in Ohio, our Columbus health care fraud defense lawyers routinely represent local physicians, pharmacists, and other providers in compliance and enforcement matters, and we have a significant track record of successfully defending all types of health care providers across the nation. Our team includes former prosecutors with the DOJ who have decades of experience in health care fraud investigations and prosecutions, and we take a team approach to defense representation which ensures that every client has the full weight of our attorneys’ collective experience on their side.
“It is very clear to me that Nick Oberheiden has a deep understanding of health law issues. Nick has been instrumental in managing and resolving many difficult legal matters. He is always relentlessly focused on the critical issues that matter most. Nick is very dedicated and available and always displays a high degree of professionalism. I would not hesitate in recommending Nick for the most important of legal matters.” – Health Care Provider, Firm Client
“We have never dealt with legal counsel who is so down to earth and compassionate toward his clients. [Dr. Nick Oberheiden] has a level of compassion and dedication that one would only expect from a family member. He is responsive and has even worked with us on weekends . . . . In a situation where we felt like there was little hope, this gentleman provided a bright light at the end of a dark tunnel. He has a heart for what he does that we don’t often see in today’s legal profession.” – Health Care Provider, Firm Client
Over 100 Years of Collective Experience in Health Care Fraud Matters
Together, our attorneys have over 100 years of experience in federal health care fraud matters, and we have handled well over 1,000 cases involving allegations ranging from administrative coding errors to intentional Medicare fraud. Regardless of the scope and nature of the allegations against you, we can use our experience with the goal to minimize the consequences of your federal health care fraud investigation. Our Columbus health care fraud defense lawyers represent licensed professionals, medical practices, health care facilities, and other individuals and organizations in Ohio and nationwide in a wide range of legal matters.
1. Billing and Coding Violations
Allegations of billing and coding violations involving Medicare, Medicaid, Tricare, and other federal health care benefit programs are becoming increasingly common as federal authorities continue to enhance their reliance on data analytics to identify targets for their investigations. Frequently, these investigations will focus on billing practices which appear to raise concerns when viewed out of context, but which in reality simply reflect the nuances of practicing in a particular geographic location. Some of the most-common alleged billing and coding violations include:
- Billing for non-allowable costs (such as operational expenses) or ineligible services (such as those rendered by an unlicensed or excluded provider)
- Billing under outdated Medicare, Medicaid, Tricare, or other program billing regulations
- Double-billing a health care benefit program, multiple benefit programs, or a benefit program and a private insurer
- Unbundling related services in order to bill at higher individual reimbursement rates
- Up-coding services in order to bill at a higher reimbursement rate than the one that should be charged
- Using the wrong billing code when submitting a reimbursement request to Medicare, Medicaid, Tricare, or another health care benefit program
2. Kickbacks and Referral Fees
Kickbacks and referral fees are also among the most common, and most misunderstood, issues involved in federal health care fraud investigations. Under the Anti-Kickback Statute, it is a federal offense to “knowingly and willfully” offer, pay, solicit, or receive remuneration, directly or indirectly, in order to induce business that is reimbursable under any federal health care program. However, proof of actual knowledge is not required, and you do not actually have to consummate a transaction in order to trigger liability under the Anti-Kickback Statute.
3. Physician Self-Referrals
The Stark Law, or physician self-referral statute, imposes strict liability for physicians who make referrals for program-reimbursed “designated health services” to entities with which they have certain types of financial relationships. “Designated health services” under the Stark Law include:
- Clinical laboratory services
- DME and medical supplies
- Home health services
- Inpatient and outpatient hospital services
- Outpatient pathology
- Outpatient prescriptions
- Parenteral and enteral nutrients, equipment, and supplies
- Physical therapy
- Prosthetics, orthotics, and related supplies
- Radiology and radiological therapy
Financial relationships that can trigger liability under the Stark Law include:
- Direct compensation arrangements
- Direct investment
- Indirect investment or compensation arrangements
- Company or practice ownership
Like the Anti-Kickback Statute, the Stark Law includes a number of safe harbors and exceptions. Successfully defending against allegations of unlawful physician self-referrals will often involve convincing federal prosecutors that one of these special statutory or regulatory protections applies. It takes an experienced team of Columbus health care fraud defense lawyers to defend accusations such as these.
4. False and Fraudulent Claims
The False Claims Act (FCA) is the primary source of legal authority involved in most health care fraud investigations. Even in cases where physicians and other providers are facing liability under the Anti-Kickback Statute or Stark Law, they will often also face FCA liability as well. This is significant, as the False Claims Act contains provisions for both civil and criminal penalties (similar to the Anti-Kickback Statute), including:
- Civil or criminal fines
- Recoupment of overbilled amounts
- Treble damages (three times the government’s actual losses)
- Loss of federal health care benefit program eligibility (program exclusion)
- Five years of federal imprisonment for each individual offense
5. Billing for Medically-Unnecessary Services, Supplies, or Equipment
Medicare, Medicaid, Tricare, and the other federal health care benefit programs only provide reimbursement for services that program administrators have deemed “medically necessary.” If a service is not medically necessary – as defined by program regulations, and not necessarily by medical standards – then not only is it not eligible for reimbursement, but any attempt to claim reimbursement can trigger allegations of health care fraud. Some of the most-common types of issues involved in so-called “medical necessity” investigations include:
- Providing treatment outside of program guidelines or beyond the program-approved length of stay
- Providing necessary services, supplies, or equipment in connection with non-necessary services (such as cosmetic surgery)
- Using higher-cost treatment options where lower-cost (and potentially lower-quality) treatment options are available
6. Billing for Services, Supplies, or Equipment Not Provided
While allegations of billing for services, supplies, or equipment not provided will occasionally be based upon evidence of intentional fraud, these investigations frequently center around issues of adequate documentation. If your business or practice has been accused of so-called “phantom billing,” it will be important to get to the bottom of the issue promptly so that you can tailor your defense strategy to the specific circumstances at hand.
7. Prescription Drug Fraud
Prescription drug fraud is an area of health care fraud enforcement that has become significantly more active with the DOJ’s decision to prosecute providers as a way to tackle opioid abuse and dependence. Pharmacies, compound pharmacies, physician-owned practices, clinics, hospitals, and other providers are being targeted with increasing frequency in investigations involving allegations of:
- Dispensing more medication than was prescribed
- Drug shorting and refill schemes
- Falsifying and forging prescriptions
- Prescribing medications that are not medically-necessary (including falsifying patient records and selling fraudulent prescriptions)
- Prescribing medications without an in-person exam
- Prescription drug diversion
8. Falsifying Patient Records and Inaccurately Reporting Test Results
Along with prescription drug fraud, various other types of fraud allegations can involve allegations of falsifying patient records as well. Here, too, thorough documentation and effective communication are critical – as preventing an investigation from leading to charges is often a matter of explaining why the assumptions of investigators about providers’ patient practices are misguided.
9. Fraudulent Physician Certifications for Home Health and Hospice Care
Successfully defending against investigations targeting home health and hospice care providers’ physician certification practices often requires a similar approach. Dealing with the physician certification process is a necessary component of providing program-reimbursed home health and hospice services. Therefore, it is often an initial source of inquiry for federal authorities seeking to target home health and hospice providers. Common allegations against home health agencies, hospices, and certifying physicians include:
- Forging physician certifications
- Paying or receiving kickbacks or referral fees in connection with physician certifications
- Relying on a physician other than the patient’s primary care physician to provide a certification
- Supplying and relying upon false and fraudulent physician certifications
10. Fraudulent Election Statements for Hospice Care
Investigations targeting home health and hospice care providers will often focus on these providers’ election statement practices as well. In addition to obtaining physician certifications (and recertifications every 60 days), home health and hospice care providers must also obtain valid election statements from their patients prior to beginning of treatment. Failure to obtain valid election statements (or maintain adequate documentation of patients’ election statements) can lead to charges under the False Claims Act and other federal laws.
Q&A: Defending Against Health Care Fraud Allegations in Columbus, OH
Q: Which federal agencies can investigate and prosecute health care providers suspected of engaging in fraudulent billing practices?
Numerous federal agencies and task forces are involved in the government’s fight against health care fraud. In cases involving Medicaid, state authorities will often be involved as well, such as the Ohio Medicaid Fraud Control Unit (MFCU). At Oberheiden, P.C., our Columbus health care fraud defense lawyers routinely represent clients in investigations involving:
- Centers for Medicare and Medicaid Services (CMS)
- Department of Defense (DOD)
- Department of Health and Human Services’ Office of Inspector General (OIG)
- Department of Justice (DOJ)
- Department of Labor (DOL)
- Drug Enforcement Administration (DEA)
- Federal Bureau of Investigation (FBI)
- Medicare Fraud Strike Force
- U.S. Attorney’s Office
Q: What is the first thing I should do after being contacted by federal authorities?
If you, or anyone in your practice has been contacted by an agent or prosecutor from one of these agencies, it is imperative that you seek experienced legal representation immediately. At this point, you cannot afford to make mistakes, and you need to get out in front of the investigation so that you are able to execute a defense strategy that is tailored to the specific focus of the government’s inquiry. To learn more about your situation, we encourage you to read: 10 Things To Do When You Are Under Health Care Fraud Investigation.
Q: Can I really go to prison for overbilling Medicare, Medicaid, or Tricare?
Yes, you can really go to prison for overbilling Medicare, Medicaid, or Tricare. If federal prosecutors believe that they have sufficient evidence of intent to pursue criminal charges under the False Claims Act, you can face up to five years of federal imprisonment for each individual alleged violation. Combined with charges for criminal conspiracy, mail fraud, wire fraud, and the various other “add-on” offenses that prosecutors commonly pursue in large-scale health care fraud cases, it is not unusual for decades of prison time to be on the table for intent cases.
Q: What are some potential defenses to health care fraud?
In order to avoid criminal punishment (including federal imprisonment), one of the most important lines of defense in many cases is to challenge the government’s evidence of intent. If prosecutors cannot prove intent, then they cannot obtain a criminal conviction. Depending upon the specific circumstances involved in your health care fraud investigation, some other potential defenses include:
- Assertion of safe harbors and exceptions under the Anti-Kickback Statute or the Stark Law
- Assertion of your Constitutional Rights (such as your right to be free from unreasonable searches and seizures)
- Challenging the government’s evidence of each element of the alleged offense
- Demonstrating that any alleged overbillings were appropriate under the then-current program billing regulations
- Demonstrating that any alleged violations were the result of honest human error and were not committed knowingly or intentionally
Why Choose Oberheiden, P.C. in Columbus, OH?
1. Our Health Care Fraud Experience
We aren’t just health care lawyers or defense lawyers. We are Columbus health care fraud defense lawyers. Our health care fraud defense attorneys have well over a century of combined experience specifically dealing with federal health care fraud investigations.
2. Our DOJ Background
Several of our attorneys began their careers as health care fraud prosecutors with the DOJ. As a result, we know health care fraud investigations from the inside out, and we are able to use this experience to execute proven defense strategies for our clients.
3. Our Consistent Results
We have resolved a notable percent of our clients’ cases without federal indictments, and to date not a single client of Oberheiden, P.C. has faced civil or criminal liability under the False Claims Act.
4. Our Team Approach
With our unique team approach, each of our attorneys plays a role in every case we handle. This allows us to leave no stone unturned and ensures that we provide our clients with the best possible legal representation.
5. Our Commitment to Success
While we resolve most of our clients’ cases during the investigative process – when necessary we do not hesitate to fight for our clients’ freedom at trial.
Schedule a Free Case Assessment at Oberheiden, P.C.
If you are facing a health care fraud investigation in Columbus, OH, we encourage you to contact us promptly for a free case assessment. To speak with the our Columbus health care fraud defense attorneys on our fraud defense team in confidence, please call (888) 519-4897 or inquire online now.