Denver, Colorado Healthcare Fraud Defense Lawyers
Skilled Healthcare Fraud Defense Attorneys Serving Denver, Colorado
Health providers – including physicians’ practices, pharmacies, hospitals, toxicology laboratories, hospices, home healthcaregivers, and others – in the Denver, CO area are currently at risk for being targeted in federal healthcare fraud investigations. Federal authorities at the U.S. Department of Justice (DOJ) and other agencies are taking aggressive measures to curb fraud, waste, and abuse in the government’s health benefit program system, and in doing so they are targeting both organized crime syndicates and legitimate health practices. These authorities are relying heavily on data analytics to identify potential targets for investigation; and, when looking solely at the numbers, it can often be difficult to distinguish between a scam and a compliant health organization.
If you are a physician, pharmacist, company owner or executive, or other individual involved with a healthcare entity that is facing an investigation, you need to take the investigation very seriously. Your business or practice could be facing enormous financial liability in addition to exclusion from Medicare, Medicaid, Tricare, and other benefit programs; and, if you personally are implicated in any alleged fraud, you could be facing substantial fines and long-term imprisonment. If you are a licensed health professional, your license could potentially be at risk as well – possibly even if the investigation does not ultimately lead to civil or criminal charges.
Defending Against Healthcare Fraud Investigations and Charges in Denver, CO
Our attorneys bring decades of experience in representing health providers in Denver, CO. With a national practice, we have successfully defended providers in fraud investigations and prosecutions around the country. Several of our lawyers held high-level positions with the DOJ, the U.S. Attorney’s Office, and other legal departments within the federal government prior to entering private practice, and all of our Denver health fraud defense attorneys have long and established track records of obtaining favorable outcomes during investigations and, when necessary, at trial.
“It is very clear to me that Nick Oberheiden has a deep understanding of health law issues. [He] has been instrumental in managing and resolving many difficult legal matters [and] is always relentlessly focused on the critical issues that matter most. Nick is very dedicated and . . . displays a high degree of professionalism. I would not hesitate in recommending Nick for the most important of legal matters.” – Satisfied Client
“The very best!”
“I hired Nick Oberheiden and Oberheiden, P.C. to defend me in a criminal healthcare matter. From the first moment I met with Nick[,] my wife and I knew that he [would provide] the help I need[ed]. And yes, Nick got me out of trouble. No charges. Case Dismissed.” – Satisfied Client
Common Allegations in Federal Healthcare Fraud Matters
In a health fraud investigation, it is possible to face allegations under a variety of different federal laws. Federal prosecutors regularly pursue multiple charges against providers suspected of defrauding Medicare, Medicaid, Tricare, and other health benefit programs. This includes charges under healthcare-specific laws as well as statutes that are more general in nature. When facing an investigation, it is critical to discern the scope and nature of the government’s inquiry as soon as possible, as the specific statute (or statutes) at issue will partially determine the defenses you have available.
Federal investigators and prosecutors commonly pursue cases based on alleged violations of:
- False Claims Act. The False Claims Act is a federal law that penalizes the submission of “false and fraudulent” claims for compensation from the government. In the healthcare context, this includes submitting inaccurate reimbursement requests to Medicare, Medicaid, Tricare, and other health benefit programs. Upcoding, unbundling, double-billing, phantom billing, billing for medically-unnecessary services, and other billing violations can all potentially trigger investigations that can lead to civil or criminal charges under the False Claims Act.
- Anti-Kickback Statute. The Anti-Kickback Statute prohibits referral arrangements that involve the payment of referral fees (referred to as “kickbacks” or “bribes”) using funds received from a federal benefit program. While the Anti-Kickback Statute contains sweeping prohibitions, there are numerous statutory and regulatory safe harbors as well, and defending against illegal kickback allegations often involves demonstrating that a safe harbor applies.
- Stark Law. The Stark Law applies specifically to physicians and related healthcare entities. This includes entities both (i) in which physicians own a financial interest, and (ii) with which physicians have compensation-based relationships. Under the Stark Law, it is illegal for physicians to refer patients to related health entities unless a safe harbor applies. Violations can lead to civil penalties and False Claims Act liability.
- Controlled Substances Laws. Allegations of prescription drug fraud can lead to severe consequences, including fines, incarceration, license revocation, and healthcare benefit program exclusion. Physicians, pharmacists, and others that are being investigated for alleged activities such as prescribing narcotic medications to drug-dependent patients, diverting prescription narcotics, and prescribing narcotics without medical justification must engage experienced legal counsel to intervene in their investigations as soon as possible.
- Healthcare Benefit Program Laws and Regulations. From the billing violations discussed above to use of fraudulent physician certifications, the list of allegations that can trigger an investigation for Medicare, Medicaid, or Tricare fraud is almost endless. At Oberheiden, P.C., we are intimately familiar with the laws and regulations that govern providers who participate in federal health benefit programs, and we rely on our experience as fraud defense attorneys and former federal fraud prosecutors to protect our clients as thoroughly and cost-effectively as possible.
FAQs: Defending Against Healthcare Fraud Allegations in Denver, CO
Q: What if my billing manager inadvertently submitted improper reimbursement requests to Medicare – can I still be penalized?
Unfortunately, yes. In our experience, the vast majority of billing violations are the result of a simple human error. However, this does necessarily insulate providers from liability. In many cases, proof of intent to commit fraud is not required to establish a statutory violation, and providers must execute meticulously-planned defense strategies in order to mitigate the risk of honest mistakes leading to substantial fines and penalties.
Q: What are the differences between civil and criminal healthcare fraud investigations?
The primary difference between a civil health fraud investigation and a criminal health fraud investigation has to do with the potential penalties involved. In a civil case, the penalties are only financial in nature (including recoupments, fines, treble (triple) damages, and program exclusion), while a criminal conviction can lead to long-term imprisonment.
When you discover that you are under investigation, you may not know whether the investigation is civil or criminal in nature. Laws such as the False Claims Act and the Anti-Kickback Statute include both civil and criminal provisions, and civil and criminal investigations can be similar in many respects. Yet, when you are facing a federal investigation, the nature of the investigation (whether it is civil or criminal) is one of the first things you need to know. When we take on the representation of a new client, one of our first priorities is to intervene in the investigation and determine whether our client is at risk for federal incarceration.
Q: What are some examples of legal compensation arrangements under the Anti-Kickback Statute and the Stark Law?
As we mentioned earlier, the Anti-Kickback Statute and the Stark Law contain numerous safe harbor provisions that exempt specific types of transactions and relationships from the prohibitions against payments for patient referrals. These safe harbors tend to be highly complex, and demonstrating that a transaction or relationship qualifies for safe harbor protection requires a thorough understanding of the law and the ability to effectively communicate with investigators and prosecutors. Some of the categories of safe harbors that we are frequently able to use to protect our clients include:
- Bona-fide employment relationships
- Certain arrangements with hospitals and ambulatory surgery centers
- Discounts and group purchasing arrangements
- Exempt investment interests
- Fair market value compensation for services
- In-office ancillary services
- Isolated transactions
- Medical staff incidental benefits
- Personal service arrangements
- Referrals for specialty services
Q: What steps are involved in defending against a federal healthcare fraud investigation?
When facing a federal fraud investigation, the first critical step is to intervene in the investigation as soon as possible. The investigators and prosecutors need to know that you are represented by counsel; and, at Oberheiden, P.C., there are additional steps we can take to quickly gather information about the investigation and begin working toward a favorable resolution. In broad terms, our approach to defending Denver-area clients in investigations involves:
- Early intervention in the investigation
- Establishing a dialogue with the investigators and prosecutors
- Conducting an internal assessment
- Developing and executing a tailored defense strategy
- Seeking to secure a favorable resolution before charges are filed