Medicaid Alternative Benefit Plan Fraud Defense

Medicaid Fraud Defense Lawyers Representing Providers Accused of Alternative Benefit Plan Abuse

The federal government is aggressively targeting healthcare providers suspected of submitting fraudulent billings under all federal healthcare programs. This includes fraud under Medicaid Alternative Benefit Plans (ABPs). If you are under investigation or facing accusations of improperly billing an ABP under your state’s Medicaid program, you are facing serious consequences, and it is important that you engage experienced Medicaid fraud defense counsel promptly.

Our Defense Lawyers Represent Providers in All Types of Medicaid Fraud Cases

Our Medicaid fraud defense lawyers have extensive experience representing clients accused of improperly receiving Medicaid payments through billing fraud and other means. We handle cases involving the U.S. Department of Justice (DOJ), Centers for Medicare and Medicaid Services (CMS), Federal Bureau of Investigation (FBI), Medicaid Fraud Control Units (MFCUs), and other enforcement authorities. These authorities use substantial resources to combat fraud in all forms, and they target pharmaceutical manufacturers, pharmacies, doctors’ offices, clinics, hospitals, home health agencies, and all other types of providers suspected of potential fraud, waste, and abuse.

Are You Facing Medicaid Fraud Allegations Involving an Alternative Benefit Plan?

If you are facing Medicaid fraud allegations involving an Alternative Benefit Plan, it is important to understand what is at stake in your case. Federal prosecutors take fraud under federal health care programs—including Medicare fraud and Medicaid fraud—very seriously. Fraud allegations can lead to civil penalties including fines, recoupments, treble damages, and loss of eligibility for federal payments. In some cases, they can lead to criminal penalties as well. When the DOJ alleges intentional provider fraud under a Medicaid Alternative Benefit Plan, prison time can also be on the table.

Potential Allegations Under the False Claims Act

Medicaid fraud involving alternative health plans is typically prosecuted under the False Claims Act (FCA). The FCA is one of several federal laws that apply to healthcare providers who bill under Medicaid and other federal programs.

Under the FCA, the submission of any false or fraudulent claim resulting in the improper receipt of Medicaid funds can lead to federal charges. Healthcare providers can face civil liability in cases involving inadvertent improper billing practices, and they can face criminal liability in cases involving allegations of intentional Medicaid fraud schemes.

Some examples of potential allegations against Medicaid providers in Alternative Benefit Plan fraud cases include:

Billing for Ineligible Services or Patients

When billing under a Medicaid plan (including an Alternative Benefit Plan), healthcare providers can only bill for eligible services provided to qualified Medicaid enrollees. Improperly billing for non-covered services under Medicaid (i.e., non-qualifying community based services, non-emergency medical transportation, and services that lack medical necessity) can lead to civil or criminal fraud allegations. Billing for eligible services provided to ineligible patients violates the False Claims Act and other federal laws designed to prevent fraud as well.

Fraudulent Billing Practices

Coding accuracy is a major issue among healthcare providers that receive federal funding through Medicaid and other federal spending programs. Upcoding, unbundling, and other intentional and unintentional billing violations are all common. If your practice is facing scrutiny from the DOJ, CMS, FBI, an MFCU, or the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) related to its Medicaid billing practices—or if it is facing scrutiny from a Unified Program Integrity Contractor (UPIC) or another auditor—you should consult with an experienced Medicaid fraud defense lawyer as soon as possible.

Retaining Improper Payments

When healthcare providers and other entities receive improper Medicaid payments, they are required to refund these payments promptly. This is true whether they willfully solicit fraudulent payments or make inadvertent billing errors. Retaining improper payments is another common—and serious—form of Medicaid fraud. While improperly retaining payments received under a Medicaid Alternative Benefit Plan may violate state law, it violates federal ant-fraud and abuse laws as well, and federal agencies like the DOJ and HHS OIG prosecute Medicaid fraud in most cases.

Anti-Kickback Statute and Stark Law Violations

The Anti-Kickback Statute prohibits healthcare providers and other entities from using Medicaid-reimbursed funds to compensate others for referring patients. Offering or accepting improper inducements in violation of the Anti-Kickback Statute can lead to civil or criminal prosecution depending on the circumstances involved. The Stark Law is a civil statute, and it prohibits “physician self-referrals” for designated health services funded through Medicaid spending.

Other Forms of Healthcare Fraud

Healthcare providers that bill under Medicaid Alternative Benefit Plans can face scrutiny for many other forms of suspected fraud as well. From falsifying Medicaid data and patients’ medical records to failing to comply with Medicaid’s administrative requirements for reimbursement eligibility, healthcare providers and other entities can (and do) face scrutiny in a wide range of circumstances. If you are facing scrutiny related to Medicaid ABP billings for any reason, we strongly encourage you to speak with one of our experienced Medicaid fraud defense attorneys right away.

What to Do if You Are Facing a Federal Medicaid Fraud Investigation

If you are facing (or your practice or business is facing) allegations of fraud under a Medicaid Alternative Benefit Plan (ABP), there are several important steps you need to take promptly. To help mitigate your risk of facing unnecessary consequences, you should:

• Engage Experienced Medicaid Fraud Defense Counsel – In this scenario, it is essential to have experienced Medicaid fraud defense counsel. Engaging a law firm should be your first priority if you are facing scrutiny from a Medicaid auditor or any federal or state law enforcement authority.  
• Conduct a Privileged Internal Medicaid Compliance Assessment – Once you engage legal counsel, your counsel will be able to conduct an attorney-client privileged internal Medicaid compliance assessment focused on identifying any and all pertinent risks.
• Develop an Informed Defense Strategy – After assessing the risks at hand, your counsel will be able to develop an informed defense strategy. Whether this involves affirmatively demonstrating compliance or preparing to defend against fraud allegations will depend on the circumstances involved.
• Be Very Careful About Sharing Information with Auditors or Investigators – In all cases, targeted healthcare providers and other entities need to be very careful about sharing information that could lead to civil or criminal enforcement action. Working closely with experienced counsel is key here as well.
• Proactively Target a Favorable Resolution – With a clear understanding of what to do (and what not to do), healthcare providers and other entities that are facing Medicaid-related scrutiny can proactively target a favorable resolution that avoids formal charges.

FAQs: What Health Care Providers Need to Know About Facing Medicaid Alternative Benefit Plan Fraud Allegations

Schedule a Free and Confidential Consultation with a Senior Medicaid Fraud Defense Lawyer Today

Our lawyers have experience representing clients in Medicaid fraud cases nationwide. If you need to defend against allegations of improperly obtaining Medicaid funds under an Alternative Benefit Plan, we strongly encourage you to get in touch. To speak with one of our senior Medicaid fraud defense lawyers in strict confidence as soon as possible, call 888-680-1745 or tell us how we can help online now.