What does it mean to be accused of federal healthcare fraud? Are you at risk for losing your Medicare, Medicaid, Tricare, VA, or DOL eligibility? Could your medical license be in jeopardy? Could you be facing insurmountable recoupments and fines? What about federal imprisonment? These are questions that Boca Raton, Florida
healthcare providers are being forced to confront with increasing frequency. While the U.S. Department of Justice (DOJ), U.S. Department of Health and Human Services (DHHS), U.S. Drug Enforcement Administration (DEA), and other federal agencies routinely investigate healthcare providers nationwide, certain geographical areas are considered “hot spots” for healthcare fraud enforcement. Boca Raton is one of these areas. With its large number of program-participating healthcare providers and program beneficiaries, Boca Raton is considered a high-risk area for federal program fraud, and federal authorities are cracking down on local physicians, pharmacists, telemedicine companies
, and other providers and entities.
What Do Boca Raton Healthcare Providers Need to Know about Federal Fraud Audits and Investigations?
1. Audits and Investigations Can Have a Variety of Different Triggers, and They Can Take Many Different Forms.
If your healthcare practice or medical business is being targeted in an audit or investigation, the first question you need to answer is, “Why?” Answering this question will then allow you to answer questions such as:
- Is the audit or investigation part of the federal government’s (and its “fee-for-service” audit contractors’) routine monitoring efforts, or has your practice or business been singled out as a possible healthcare fraud perpetrator?
- If you are facing an investigation, is your practice or business being targeted, or are you currently being treated as a witness in an investigation into another provider?
- If you are facing an investigation, is the investigation civil in nature, or are federal prosecutors seeking evidence to pursue a criminal indictment?
Identifying the audit contractor or federal agency (or agencies) involved in the audit or investigation can provide significant insight into the scope and nature of the inquiry as well. At Oberheiden, P.C., our federal healthcare fraud defense lawyers
have extensive experience representing clients in matters involving:
- Medicare Administrative Contractors (MACs)
- Recovery Audit Contractors (RACs)
- Unified Program Integrity Contractors (UPICs)
- Zone Program Integrity Contractors (ZPICs)
- DOJ and DEA
- DHHS Office of Inspector General (OIG)
- U.S. Attorney’s Office
- Centers for Medicare and Medicaid Services (CMS)
- Federal Bureau of Investigation (IRS)
- Internal Revenue Service (IRS)
- U.S. Department of Defense (DOD)
- U.S. Department of Labor (DOL)
- U.S. Department of Veterans Affairs (VA)
We can use this experience to quickly assess all aspects of your audit or investigation and provide immediate defense representation for your practice or business.
2. The Definition of “Healthcare Fraud” is Far Broader than Most Practitioners and Company Executives Realize.
In the context of the federal healthcare system, “fraud” is a broad term that encompasses virtually any
practice that results in an improper reimbursement request being submitted to Medicare, Medicaid, Tricare, the DOL, or the VA. With each individual reimbursement request constituting a separate “fraudulent claim,” it is not unusual for healthcare providers and businesses to face numerous allegations carrying the potential for substantial liability. Too often, practitioners and business executives dismiss the risks of healthcare fraud audits and investigations because they know that they haven’t intentionally done anything wrong. However, this is a dangerous mistake that is predicated on a fundamental misunderstanding of the federal government’s definition of “healthcare fraud.”
3. Audits and Investigations Can Lead to the Same Severe, Practice-Threatening Consequences.
While audits and investigations are very different inquiries, they can ultimately lead to the same outcomes. Another all-to-common mistake we see is practice owners and business executives assuming that the worst that can result from an audit is modest recoupment liability. However, CMS’s fee-for-service audit contractors have been endowed with the authority to impose various types of penalties on healthcare providers. Furthermore, when MACs, RACs, UPICs, and ZPICs find evidence of fraud, they are required
to refer program-participating providers to CMS or the DOJ for investigation and possible prosecution.
4. All Types of Healthcare Providers and Medical Businesses are Being Targeted in Audits and Investigations in Boca Raton.
While many audits and investigations target providers that work directly with patients, doctors aren’t the only ones being targeted in healthcare fraud audits and investigations in Boca Raton. In today’s environment of aggressive federal healthcare fraud enforcement, all
providers and other entities that bill Medicare, Medicaid, Tricare, the DOL, and the VA are at risk for being audited and investigated. This includes (but is not limited to):
- Clinics, hospitals, and other medical facilities
- Dentists and dental practices
- Durable medical equipment (DME) distributors
- Federally Qualified Health Centers (FQHCs)
- Pharmacists and pharmacies
- Telemedicine companies
- Testing laboratories
- Physician assistants (PAs), nurse practitioners (NPs), and other licensed medical professionals
5. Providers Must Respond to Requests for “Interviews,” Audit Letters, Civil Investigative Demands (CIDs), Subpoenas, and All Other Forms of Contact with Extreme Caution.
While many inquiries begin with formal Civil Investigative Demands (CIDs) and subpoenas, it is not unusual for federal agents to request “interviews” or to simply show up at program participants’ doors and begin asking questions. Regardless of how you are initially contacted, your response needs to be measured and based on the advice of experienced legal counsel. Once again, audits and investigations need to be treated with equal care, and providers and businesses should not provide any
statements or records without first obtaining the advice of an experienced federal healthcare fraud defense attorney.
6. Many Healthcare Fraud Investigations Target “Conspiracies,” Which Do Not Require Proof that Healthcare Fraud was Actually Committed.
While most healthcare fraud investigations target allegations of billing and coding fraud
, unlawful kickbacks and referral fees
, and other fraudulent practices
, it is not necessary to actually defraud the government in order to face federal liability. Healthcare fraud conspiracy investigations
can target multiple providers and entities based on allegations of “scheming” to unlawfully obtain Medicare, Medicaid, and other federal program funds. In many cases, alleged co-conspirators will have only very tenuous connections, and in large-scale investigations it is not unusual for alleged co-conspirators to not even be aware of one another’s existence.
7. Lack of Intent is Not a Complete Defense to Federal Liability for Healthcare Fraud.
While challenging the government’s evidence of intent may save you from criminal prosecution, intent is not required to establish civil liability for healthcare fraud. Furthermore, under the federal doctrine of “constructive intent,” federal prosecutors do not need to prove that you purposefully overbilled the government in order to obtain a criminal conviction.
8. Healthcare Providers and Medical Businesses Can – and Should – Take an Active Role in Federal Healthcare Fraud Audits and Investigations.
When facing an audit or investigation, doing nothing is the surest way to face recoupment liability and other penalties. Healthcare providers and medical businesses must actively defend themselves, and this means aggressively intervening in the process. When we represent healthcare providers and medical businesses in audits and investigations, we make contact with the auditors or federal agents as soon as possible, and we take an aggressive approach that involves challenging the auditors’ and investigations’ assumptions, methodologies, and conclusions from all angles.
9. Audits Can Lead to Investigations, Investigations Can Lead to Charges, and Charges Can Lead to Trials.
Audits and investigations are not stand-alone events. MAC, RAC, UPIC, and ZPIC audits can trigger investigations if auditors believe that they find evidence of fraud, and investigations can lead to civil or criminal charges without an effective defense. Once charges have been filed, federal prosecutors will begin preparing their case for trial.
10. Engaging Highly-Experienced Defense Counsel Early in the Process is the Key to Avoiding Unnecessary Consequences.
At Oberheiden, P.C., we have a proven track record
of successfully defending clients during federal healthcare fraud audits and investigations. We have resolved the majority of our clients’ cases without charges being filed, and to date we have resolved every False Claims Act investigation we have handled without any civil or criminal liability for our client. With a defense team that includes several former DOJ prosecutors, we off our clients centuries of combined experience on both sides of high-stakes federal healthcare fraud matters.
Contact the Federal Healthcare Fraud Defense Lawyers at Oberheiden, P.C.
If you are facing a MAC, RAC, UPIC, or ZPIC audit, or if your healthcare practice or medical business is under investigation for fraud in Boca Raton, you need to speak with an attorney as soon as possible. To speak with a federal healthcare fraud attorney
about your situation in confidence, call us at 888-680-1745 or request a free case assessment online
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