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Georgia Medicare Fraud Defense

For Medicare-participating health care providers in Georgia, audits and investigations can lead to recoupments, fines, and other penalties. If federal prosecutors accuse you of intentional Medicare fraud, prison time could also be on the table.

The federal Medicare system provides critical access to care while also providing many health care providers with the income they need to stay afloat. Each year, Medicare pays hundreds of billions of dollars for patient services, and it is currently the second-largest program in the federal budget after Social Security.

Unfortunately, Medicare’s enormous size also means that it is a prime target for fraud and abuse; and this, in turn, means that federal authorities closely monitor program billings and expenditures. While this results in takedowns of large-scale Medicare fraud scams, it also results in many legitimate health care providers facing substantial penalties despite their efforts at Medicare compliance.

Senior Medicare Fraud Defense Lawyers Representing Georgia Health Care Providers

For health care providers in Georgia, allegations of intentional and unintentional Medicare fraud can stem from two forms of inquiry: audits and investigations. Audit contractors working with the Centers for Medicare and Medicaid Services (CMS) conduct automated, semi-automated, and complex audits of providers’ Medicare billings, and they have the authority to impose recoupments, pre-payment review, and other penalties. Investigations can be triggered by a variety of different factors; and, depending upon the specific allegations involved, Medicare fraud investigations can involve federal agencies ranging from the U.S. Department of Justice (DOJ) and the Office of Inspector General (OIG) to the Drug Enforcement Administration (DEA), the Federal Bureau of Investigation (FBI), and the Internal Revenue Service (IRS).

If your Georgia health care practice or medical business is being targeted in an audit or investigation, it is important that you seek experienced legal representation. Both types of inquiries have the potential for severe consequences, as auditors routinely refer providers to the DOJ and the OIG for civil or criminal prosecution. At Oberheiden, P.C., our senior Medicare defense attorneys have centuries of combined experience on both side of Medicare audits and investigations, and we can use this experience to protect you against unnecessary, costly, and potentially even practice or business-threatening consequences.

Former Federal Health Care Fraud Prosecutors with Experience on Both Sides of Medicare Audits

Within the Medicare system, audits are conducted by private companies that have contracts with CMS. These companies operate on a “fee-for-service” basis, which means that they are compensated based upon the volume of recoupments they secure on behalf of CMS. As a result, while a Medicaid audit is supposed to focus on identifying all improper billings (both overpayments and underpayments), in practice these audits are much more akin to investigations focused solely on finding evidence of Medicare fraud.

There are three primary types of audit contractors under CMS’s “fee-for-service” audit program: Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs). Currently, the MACs, RACs, and ZPICs operating in Georgia are:

  • MACs: CGS Administrators, LLC and Palmetto GBA, LLC
  • RAC: Cotiviti LLC
  • ZPIC: AdvanceMed

While MAC, RAC, and ZPIC audits involve many similarities, there are some critical differences as well; and, as a result, when facing a Medicare audit, it is essential to have legal counsel experienced in your particular type of audit. Our attorneys have handled more than 1,000 Medicare audits involving MACs, RACs, and ZPICs in Georgia and across the country, both in their former roles as DOJ prosecutors and in their current capacity as Medicare fraud defense lawyers.

1. MAC Audit Defense

Medicare Administrative Contractor (MAC) audits are invasive and time-consuming, and they can lead to substantial financial liability for health care providers. Mistakes by auditors and providers’ personnel can have equally-costly consequences, and mistakes by auditors are far more common than you might imagine. In fact, when representing home health and hospice agencies, durable medical equipment (DME) companies, and other Medicare Part A and Part B providers in MAC audits, a key component of our defense strategy involves carefully scrutinizing and second-guessing auditors’ methodologies, assumptions, and conclusions in order to expose flaws and demonstrate our clients’ compliance.

Learn more about our MAC audit defense services.

2. RAC Audit Defense

RAC audits can have similar consequences to MAC audits, and they are subject to the same risks, flaws, and shortcomings as well. As a result, Medicare-participating providers must engage experienced legal counsel in order to avoid being punished for billings that were fully compliant at the time they were submitted. We provide comprehensive and proactive representation for Georgia health care providers during RAC audits, actively challenging auditors’ practices and working quickly to secure a favorable result that prevents further government inquiry.

Learn more about our representation for health care providers facing RAC audits in Georgia.

3. ZPIC Audit Defense

ZPICs are responsible for auditing providers’ billings under Medicare Parts A and B (hospital, skilled nursing, home health, provider and durable medical equipment claims), Part C (Medicare Advantage health plans), and Part D (prescription drug plans), as well as billings involving coordination of Medicare Medicaid reimbursements. ZPIC audits often closely resemble federal investigations; and, in many cases, ZPICs will work in close coordination with the DOJ, FBI, OIG, and other federal law enforcement agencies.

Learn more about our ZPIC audit defense strategies.

Proven Results in Medicare Fraud Investigations, Grand Jury Proceedings, and Trials

1. Avoiding Charges During a Medicare Fraud Investigation

While there are three primary types of Medicare audits, there are two primary forms of federal Medicare fraud investigations: civil and criminal. Although both types of investigations have the potential for severe consequences, facing a criminal investigation means facing possible prison time; and, as a result, it is critically important to keep Medicare fraud investigations civil in nature whenever possible.

We represent health care providers in Georgia and nationwide in civil and criminal Medicare fraud investigations involving all federal law enforcement agencies and task forces. This includes the DEA, DOJ, FBI, IRS, and OIG, as well as the Medicare Fraud Strike Force, the Prescription Interdiction & Litigation (PIL) Task Force, and other authorities. When representing clients in Medicare fraud investigations, we take an aggressive approach that emphasizes prompt intervention and pre-charge resolution; and, to date, we have resolved the majority of our clients’ investigations without civil or criminal charges being filed.

Our experience includes successfully representing health care providers and other Medicare-participating businesses in Medicare fraud investigations involving allegations of:

  • Billing for medically-unnecessary services and supplies
  • Billing for services not provided
  • Fraud involving compounded medications, telemedicine, VA addiction centers, and other specialized types of services and providers
  • Falsification of patient and billing records
  • Lack of medial records and other substantiating documentation
  • Opioid and other prescription-drug related billing violations
  • Payment and receipt of illegal kickbacks and referral fees
  • Unbundling
  • Upcoding
  • Other intentional and unintentional billing and coding violations

When facing a Medicare fraud investigation, among the various other mistakes you need to avoid, it is imperative that you not make any assumptions about why you are under investigation or your risk of being charged. Federal agents and prosecutors can pursue charges under a wide variety of health-care-specific and non-health-care-specific statutes; and, even if you have not knowingly or intentionally overbilled Medicare, this does not necessarily mean that you are safe from prosecution. Our attorneys can use their experience to quickly assess your potential exposure, determine whether any remedial action is necessary, and deal with the authorities on your behalf in order to try to protect you from being charged.

2. Grand Jury Subpoena Defense

If you have received a grand jury subpoena, this means that federal prosecutors believe sufficient evidence exists to establish probable cause to charge you with criminal Medicare fraud. This is an extremely serious matter, and you must do everything in your power to protect yourself against an indictment. Our attorneys have extensive experience on both sides of grand jury proceedings involving allegations of Medicare fraud, and we can represent you in all aspects of responding to your subpoena. This includes:

  • Determining whether you have grounds to challenge the subpoena, either in whole or in part;
  • Determining whether you have an obligation to provide documents in response to the subpoena;
  • Preparing your grand jury testimony by anticipating possible questions and formulating appropriate answers;
  • Taking all action necessary to protect information and documents that you are not legally-required to disclose, including communications subject to the attorney-client privilege; and,
  • Representing you in the courthouse during the grand jury proceedings (you are not entitled to legal representation in the courtroom itself).

3. Skilled Trial Representation for Civil and Criminal Medicare Fraud Cases

If you have been charged and are awaiting trial in the Norther, Middle, or Southern District of Georgia, our attorneys can fight to protect you against a conviction. We have a substantial track record of securing favorable results prior to and during trial, including having indictments dismissed, negotiating pleas that protect our clients’ practices and businesses, and securing acquittals in court. At this point, you do not have any time to waste, and we encourage you to contact us immediately to speak with a member of our Medicare fraud defense team in confidence.

Schedule a Free and Confidential Consultation at Oberheiden, P.C.

For more information about how our Medicare fraud defense team can help protect your business or practice, please contact us to schedule a free and confidential consultation. To speak with one of our senior defense lawyers as soon as possible, call 888-519-4897 or tell us how to reach you online now.

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