Medicaid Early and Periodic Screening Fraud Defense

We Represent Providers Accused of Fraud Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a Medicaid program that is intended to identify the medical necessity of various forms of treatment at an early age. Healthcare providers can render services under EPSDT to qualifying patients under their state Medicaid program, and they can receive reimbursements for services rendered.

However, due to improper payment requests and other forms of fraud under the EPSDT program, providers have come under increasing scrutiny in recent years. Along with fee-for-service auditors working with the Centers for Medicare and Medicaid Services (CMS), governmental authorities including Medicaid Fraud Control Units (MFCUs), the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), and the U.S. Department of Justice (DOJ) are actively targeting Medicaid early and periodic screening fraud as well.

Defending Against Allegations of Healthcare Fraud Under the Medicaid EPSDT Program

We defend Medicaid providers facing all types of fraud allegations under the EPSDT program. We defend providers accused of other forms of Medicaid and Medicare fraud as well. Facing fraud allegations under a federal health care program is a serious matter, and targeted providers must be prepared to protect themselves by all means available.

Our lawyers represent health care providers in matters involving allegations of:

Fraudulent Medicaid Billings Under the False Claims Act

Health care providers that improperly bill federal programs can face steep penalties under the False Claims Act (FCA). Under the FCA, submitting a “false or fraudulent claim” to Medicaid can lead to civil penalties if the improper billing was inadvertent, and it can lead to criminal penalties if the improper billing was willful.

If you are facing allegations of improperly receiving Medicaid payments under the EPSDT program, avoiding unwarranted liability may involve demonstrating adherence to an effective billing compliance program. However, if your business’s billing practices are not compliant, you will need to take a different approach. Our lawyers can assess the circumstances at hand, and then we can develop and execute a custom-tailored defense strategy designed to protect your business’s ability to receive Medicaid payments and avoid charges from federal prosecutors.

Violations of the Anti-Kickback Statute and Stark Law

The Anti-Kickback Statute and Stark Law prohibit Medicaid-participating healthcare providers and other businesses from using their federal funding to provide compensation for referrals. Under these federal laws, providers and other businesses can face liability if they willfully solicit, receive, offer, or pay an unlawful referral fee or any other form of unlawful remuneration.

Similar to the False Claims Act, the Anti-Kickback Statute and Stark Law are anti-fraud and abuse laws that allow the HHS OIG, DOJ, state Medicaid agencies, and other authorities to pursue enforcement in a wide range of circumstances. We assist providers and other businesses with defending against these enforcement actions—relying on their compliance efforts when possible and disputing the government’s evidence of suspected fraud when necessary.

Other Forms of Healthcare Fraud

Along with facing allegations of EPSDT fraud, healthcare providers and other businesses targeted in Medicaid program integrity audits and investigations can also face a wide range of other allegations. This makes it critical to take an informed approach to responding to these inquiries. Even if an audit or investigation is initially focused on your practice’s or business’s Medicaid billings under the EPSDT program, red flags in your practice’s Medicaid data could lead to scrutiny of its other billings as well.

This includes scrutiny that could lead to allegations of:

Behavioral Health Fraud

Behavioral health fraud is a hot-button issue in the Medicaid-funded healthcare system as well. If a patient’s medical records or a provider’s billing records suggest that the provider has billed for behavioral health services improperly, this can lead to substantial liability exposure.

Community-Based Services Fraud

Inappropriate utilization of community-based services and other related forms of fraud can lead to substantial liability exposure as well. Services provided to ineligible patients, using false records to substantiate Medicaid billings, coding accuracy, and noncompliance with Medicaid’s administrative requirements are all common issues in these cases.

Durable Medical Equipment (DME) Fraud

Durable medical equipment suppliers and healthcare providers can both face allegations of durable medical equipment (DME) fraud under Medicaid. From coding fraud to billing for DME provided to patients who do not qualify for rehabilitative services, numerous intentional and inadvertent Medicaid billing violations can come to light during audits and investigations.

Home Health Care Fraud

Home health care fraud is also a priority enforcement area for HHS OIG, the DOJ, and other federal and state agencies, as well as the fee-for-service contractors that conduct audits on behalf of CMS. Fraudulent billings by home health agencies, improper payments for referring patients to nursing facilities and other healthcare providers, and other fraudulent practices can all lead to civil or criminal penalties for failure to satisfy participating providers’ statutory and regulatory requirements.

About Our Healthcare Fraud Defense Practice

Within our healthcare fraud defense practice, we represent providers and other businesses that bill Medicare, Medicaid, and other federal healthcare programs. This includes doctor’s offices, clinics, hospitals, laboratories, and other facilities, as well as DME suppliers, Medicaid managed care organizations (MCOs), and other entities involved in the federally funded healthcare system.

Our lawyers have extensive experience defending providers and other businesses against all types of Medicaid fraud allegations, and we rely on this experience when representing clients during Medicaid audits and investigations. From provider enrollment fraud to submitting fraudulent Medicaid and Medicare data to obtain reimbursements, our experience runs the gamut, and we have an extensive network of defense lawyers who are available to provide representation nationwide.

For clients that bill under the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program, our services include:

• Medicaid audit defense
• Medicaid fraud investigation defense
• Defense against administrative and civil enforcement actions
• Defense against criminal Medicaid fraud charges
• Defense against professional disciplinary actions

We provide comprehensive Medicaid compliance services as well; and, if your practice or business is facing scrutiny related to a Medicaid billing compliance failure, we can help you make sure your personnel do not make similar mistakes going forward. To learn more about what we can do to help, contact us for a free and confidential consultation today.

FAQs: Defending Against Fraud, Waste, and Abuse Allegations Under Medicaid

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

If you need defense counsel for an audit, investigation, or civil or criminal enforcement proceeding involving Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program, we encourage you to contact us right away. Call 888-680-1745 or contact us online now to arrange a free and confidential consultation as soon as possible.