Medicaid Mandatory Benefits Fraud Defense

We Defend Providers Accused of Healthcare Fraud Related to Mandatory Medicaid State Plan Benefits

Medicaid payments are an essential source of federal funding for numerous types of healthcare providers and other businesses. The Centers for Medicare and Medicaid Services (CMS) dispense hundreds of billions of dollars under Medicaid each year, and Medicaid has long been among the most important federal health programs for both patients and providers.

The Current Mandatory Services Under Medicaid

Under the Medicaid program, states are required to administer certain types of benefit programs. These are known as mandatory Medicaid state plans. Currently, state Medicaid agencies are required to fund participating health care providers that provide the following services:

• Transportation to medical care
• Inpatient hospital services
• Outpatient hospital services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Nursing facility services
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services
• Family planning services
• Tobacco cessation counseling for pregnant women
• Physician services
• Home health services
• Nurse Midwife services
• Certified pediatric and family nurse practitioner services
• Freestanding birth center services
• Medication Assisted Treatment (MAT)
• Routine patient costs for beneficiaries enrolled in qualifying clinical trials
• Concurrent care for children receiving hospice

Since these are mandatory state Medicaid programs, fraud is a very real concern. Medicaid audits have revealed extremely high rates of fraud under these programs in many states—and, according to the U.S. Government Accountability Office (GAO), the national improper payment rate currently stands at about six percent. As a result, federal authorities are aggressively working to claw back fraudulently obtained Medicaid funds, and providers nationwide are facing audits and investigations focused on their federal payments.

Types of Mandatory Medicaid Benefit Cases We Handle

Our healthcare fraud defense attorneys represent providers and other businesses that are facing Medicaid audits and Medicaid fraud investigations across the country. We have extensive experience in the area of Medicaid fraud defense; and, along with handling audits and investigations, we handle civil and criminal Medicaid fraud cases as well.

Several of our attorneys are former federal prosecutors. As a result, we have an in-depth understanding of how the government handles these cases. We defend clients that are facing Medicaid-related scrutiny from the U.S. Department of Justice (DOJ), U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), Medicaid Fraud Control Units (MFCUs), and other authorities in cases involving allegations of:

Improper Billings Under the False Claims Act

The False Claims Act prohibits healthcare providers and other entities from submitting “false or fraudulent” claims for reimbursement under Medicaid. While most cases under the False Claims Act involve exposure to civil penalties, federal prosecutors can pursue criminal charges in cases involving allegations of intentional fraud. Some examples of allegations that can lead to civil enforcement actions (or, in some cases, criminal convictions) under the False Claims Act include:

• Billing Medicaid for services that lack medical necessity
• Billing Medicaid without conducting proper eligibility determinations
• Double-billing Medicaid and private health insurance
• Improper billings under managed care plans
• Falsifying patients’ medical records in order to bill Medicaid
• Drug diversion and other prescription-related Medicaid violations
• Maintaining insufficient documentation of Medicaid compliance
• Failure to comply with Medicaid’s other administrative requirements
• Failure to take adequate steps to ensure compliance program integrity and reduce fraud
• Identity theft and other forms of beneficiary fraud

Again, these are just examples. Ultimately, federal authorities will target any improper practices that result in the loss of taxpayer dollars. As a result, audits and investigations under the False Claims Act present substantial risks, and targeted providers and other entities must be prepared to defend themselves effectively.

Improper Payments Under the Anti-Kickback Statute and Stark Law

The Anti-Kickback Statute and Stark Law prohibit physicians, suppliers, and other individuals and entities from using Medicaid-reimbursed funds to compensate for patient referrals. Illegal kickbacks under these federal laws can take many different forms; and, while there are several types of legitimate financial relationships within the healthcare industry, targeted individuals and entities must be able to affirmatively demonstrate that a relevant exception or “safe harbor” applies.

Other Forms of Medicaid Fraud and Abuse

Along with False Claims Act, Anti-Kickback Statute, and Stark Law violations, state and federal authorities are targeting other forms of Medicaid fraud and abuse under mandatory programs as well. Our healthcare fraud defense attorneys are available to handle matters involving all federal and state agencies, as well as state auditors and fee-for-service audit contractors working with the Centers for Medicare and Medicaid Services (CMS).

Clients We Serve

Within our Medicaid fraud defense practice, we represent all types of healthcare providers and other entities that bill Medicaid for items and services. This includes, but is by no means limited to:

• Ambulance service providers
• Durable medical equipment suppliers
• Home health agencies
• Hospice care providers
• Hospitals and healthcare systems
• Mental health treatment providers
• Nursing homes
• Occupational and physical therapists
• Pain clinics
• Physicians and physicians’ offices

If your practice or business is facing scrutiny related to its billings under a mandatory Medicaid state plan, our attorneys can promptly intervene, assess the risks involved, and execute a comprehensive defense strategy focused on avoiding unnecessary consequences. Our attorneys are available to provide representation on an emergency basis when necessary.

What To Do if You are Facing Medicaid Fraud Allegations from the Federal Government

If you are facing (or at risk of facing) Medicaid fraud allegations from the federal government, you need to prioritize your defense. In this scenario, it will be important to:

1. Engage Experienced Defense Counsel Promptly

Defending against a Medicaid billing audit or Medicaid fraud investigation requires experienced legal representation. With this in mind, you should engage experienced defense counsel promptly.

2. Assess the Risks At Hand

Once you engage experienced defense counsel, your law firm will be able to assess the risks at hand. This includes assessing whether your practice or business is at risk of facing civil or criminal penalties.

3. Execute a Comprehensive and Custom-Tailored Defense

In all scenarios, a comprehensive and custom-tailored defense is critical. Due to the high fraud rate under mandatory Medicaid benefit programs, targeted individuals and entities cannot afford to take chances.

FAQs: Defending Against Health Care Fraud Allegations Under Mandatory Medicaid Benefit Programs

Speak with a Senior Medicaid Fraud Defense Attorney at Oberheiden P.C. in Strict Confidence

If you would like to speak with one of our Medicaid fraud defense attorneys, we encourage you to contact us promptly. The sooner we get involved, the more we can do to help. To schedule a complimentary and strictly confidential consultation with a senior attorney as soon as possible, call us at 888-680-1745 or tell us how we can reach you online now.