Healthcare Fraud Defense

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What is Healthcare Fraud?

The scheme to defraud a healthcare program normally involves false or fraudulent representations designed to access something of value— usually money. The intent of the accused is almost always the central issue at any healthcare fraud trial. Many times errors in billing and coding make up a large part of the government’s case against a defendant. That being said, the mere fact that there are errors in bills and coding submitted does not necessarily mean that a defendant had the requisite intent to defraud a health insurance program.

Burden of Proof

When an individual is accused of healthcare fraud, the government has to prove that the defendant engaged in a scheme to steal from a healthcare program, such as Medicare, DOL, Medicaid, Tricare, another government insurance program or a private insurance program.

As seen, healthcare fraud is a generic term that encompasses a variety of conduct designed to illegally obtain a financial benefit of a provider to the detriment of the state or federal government. The following list is not exclusive, but it summarizes some of the most common fraud examples.

How Our Experienced Healthcare Fraud Defense Lawyers Have Resolved Healthcare Fraud Cases

Most healthcare fraud cases are based on the theory that a medical provider or a healthcare business (lab, pharmacy, hospital, home health agency) submitted fraudulent billing claims to Medicare, Medicaid, Tricare, or a commercial insurance company. Because billing mistakes are not uncommon in an industry known for its regulatory complexity, for the government to be involved, the alleged fraud must be widespread, systematic, and financially significant. In this context, billing errors are financially significant if the received reimbursement exceeds tens or even hundreds of thousands of dollars. “Fraud” is a fairly undefined term and in most cases the government will allege that a healthcare service lacked medical necessity, was outside the accepted standards of care (e.g. excessive testing), was billed too high, or was billed for but not provided.

Oberheiden P.C. has proven that each of these scenarios and other health care fraud charges are fixable. The sooner we get involved, the easier it is to resolve the matter. | 888-680-1745

You will know that you are under investigation if you or your business receives a healthcare audit request, a CID (Civil Investigative Demand), a subpoena from the Department of Health and Human Services (HHS) Office of Inspector General (OIG), a Grand Jury Subpoena from the Department of Justice (DOJ), or, if the case is already advanced, if your business experiences a federal search warrant or an indictment. An experienced attorney will understand the nuances of each of these scenarios and tailor a specific defense strategy.

Federal Healthcare Fraud (18 U.S.C. 1347)

• United States v. Client: Client was indicted for Medicare Fraud. The damage amount was $ 7m. Nick obtained probation for his client.
• United States v. Client: Client was indicted for Medicare Fraud. The damage amount was $ 3m. Nick obtained probation for his client.
• United States v. Client: Client was indicted for Medicaid Fraud. The damage amount exceeded $ 1m. Nick obtained probation for his client.

See 100+ more examples of Oberheiden P.C.’s winning healthcare fraud cases here.

Anti-Kickback Law (42 U.S.C. 1320a-7b)

One of the most common allegations in healthcare fraud investigations are so-called kickbacks. Unlike most other industries, healthcare laws prohibit certain types of referral incentives to protect the integrity and independence of a physician’s professional judgment. Even though virtually anything of value may qualify as a kickback (not just straight payments, but also indirectly through physician distributions in MSOs or medical directorship agreements etc.), most kickback cases are surprisingly defendable. A successful client defense requires two attorney skillsets: a superb healthcare law understanding as well as the ability to lead tough negotiations through compelling arguments. The following are just a few representative examples of how Oberheiden P.C. has successfully defended civil and criminal kickback cases across the entire country.

See 100+ more Anti-Kickback examples of Oberheiden P.C. cases here.

False Claims Act (18 U.S.C. 287)

Most FCA cases originate as whistleblower cases. That is, someone, often a former employee or a competitor, reports alleged fraud to the government by filing a lawsuit in an effort to later collect a reward. Targets of these whistleblower cases often find out about the existence of an investigation when they receive a Civil Investigative Demand (CID) or another form of a government subpoena (e.g. OIG subpoena) requesting documents and corporate information. The absolute priority in all of these defense cases is to make sure that the investigation does not turn into a criminal case—that is something Oberheiden P.C. has accomplished in every single whistleblower case. By the same token, Oberheiden P.C. is an asset protection specialist and protected the financial stability of its clients by dismissing or favorably settling these types of cases (e.g. in Los Angeles, in Florida, in Houston, in Philadelphia, in Dallas, in Portland, in Ohio etc.).

See 100+ more False Claims Act defense examples of Oberheiden P.C. here.

Aggravated Identity Theft

Aggravated identity theft is a good illustration to understand how important it is to be represented by trusted, experienced health care fraud defense attorneys. Recently, the Justice Department started to add aggravated identity theft to healthcare fraud indictments. Each count contains a mandatory two-year imprisonment. That means, probation is not an option. Oberheiden P.C. saw this trend quickly, and has successfully argued why aggravated identity theft is simply not applicable in the case—and saved clients from years of unnecessary prison time. Again, don’t gamble with your future. Call Oberheiden P.C. today.

See 100+ more examples of how Oberheiden P.C. defended federal government charges and felonies here.

Federal Conspiracy (18 U.S.C. 1349)

Many federal healthcare fraud cases are brought against medical providers and others as a conspiracy. The government essentially claims that multiple people have contributed something to the overall success of a fraud scheme. Let’s take the example of a marketer (M), a doctor (D), and a pharmacy (P). If a M unlawfully incentivizes D to send referrals to the pharmacy (“kickbacks”), then all three individuals may be charged by way of a conspiracy: the marketer for bribing, the doctor for accepting the bribe, and the pharmacy for billing claims that were based on a kickback. Oberheiden P.C. knows how to break that chain. We have successfully defended against hundreds of conspiracy charges, call us now to see how we did it!

See 100+ more examples of how Oberheiden P.C. avoided or defended federal conspiracy charges here.

Our Federal Defense Lawyers Represent Clients in Federal Healthcare Fraud Cases Nationwide – Including all CMS, DEA, DOJ, and OIG Matters

Regardless of your role within the healthcare industry, facing federal fraud allegations is an extremely serious matter. If federal agents are targeting your business or practice based upon allegations of Medicare, Medicaid, Tricare, or Department of Labor (DOL) fraud, failing to find the best healthcare defense could result in exposure to significant civil or criminal penalties.

Federal healthcare fraud allegations can take a variety of different forms, and federal prosecutors can pursue civil and criminal healthcare fraud charges under a multitude of federal statutes. As a result, when facing a healthcare fraud investigation on the federal level, a critical early step is to determine the scope and nature of the allegations against you. Are you being accused of overbilling Medicaid or Tricare or submitting false claims? Are you being accused of using Medicare-reimbursed funds to pay “kickbacks” or referral fees? Are you being accused of improperly prescribing, dispensing, or billing for opioid medications? Until you know why you are being targeted, you simply have no way of asserting an effective defense.

At Oberheiden, P.C., a significant portion of our practice is devoted to defending clients in federal healthcare fraud matters. When you engage our federal defense team to represent you, our healthcare fraud attorneys will work to quickly get to the bottom of the government’s investigation. To find out why you are being targeted and what penalties are on the table, call 888-519-4897 for a free and confidential case assessment from one of our senior healthcare fraud defense lawyers.