Fresno Health Care Fraud

Our health care fraud defense team brings decades of experience to representing individual providers, company executives, and health care organizations in federal investigations. If your Fresno, CA, business or practice is under investigation, call (214) 692-2171 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 health care 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 health care business or practice, you will need experienced legal representation.

Our health care fraud defense team represents individual and business clients in health care 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 Health Care Fraud Investigations in Fresno

What does it mean to be under investigation for “health care fraud”? This is a surprisingly complicated question, and there is not one single answer that will apply to all providers in all cases. Health care 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 health care fraud investigations will often involve allegations under multiple civil and criminal laws.

As a result, when defending against a federal health care 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 (214) 692-2171 now.

What Practitioners and Business Owners in Fresno, CA, Need to Know about Federal Health Care Fraud Investigations

1. The False Claims Act

The False Claims Act (FCA) applies to all health care 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 health care 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 health care 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 Health Care Fraud Statute

The health care 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 health care benefit program . . . [or to obtain] money or property owned by, or under the custody or control of, any health care 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 health care 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 health care 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 health care program billing regulations can trigger liability under the False Claims Act. Billing and coding violations can trigger Anti-Kickback Statute, Stark Law, and health care 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 health care 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.

5 Reasons to Choose Oberheiden, P.C., in Fresno, CA

Why do health care providers in Fresno, CA, and nationwide trust Oberheiden, P.C.’s federal health care fraud defense team?

  • We have a long record of achieving favorable outcomes in health care 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 500 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 Us for a Free and Confidential Consultation

If you need legal representation for a federal health care fraud investigation in Fresno, contact us now to schedule a free initial consultation. To discuss your case in confidence, call (214) 692-2171 or tell us how to reach you online now.

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