Baltimore Healthcare Fraud Defense Lawyers

With a team that includes former senior healthcare fraud prosecutors at the U.S. Department of Justice (DOJ), our firm is uniquely positioned to defend physicians, hospitals, and other providers in federal fraud investigations. If your Baltimore healthcare business or medical practice is under investigation, call 888-680-1745 for a free consultation with our Baltimore healthcare fraud defense lawyers.

Compliance with federal healthcare benefit billing rules is a prime part of a profitable business or practice. Whether you treat patients, dispense medications, or sell durable medical equipment (DME), the Medicare, Medicaid, and Tricare billing guidelines are stringent. Compliance programs are time-consuming and expensive. For some healthcare providers in Baltimore, it’s not enough.

Increasingly, Baltimore area providers are targets in federal investigations with claims of healthcare fraud. These investigations typically focus on providers’ billing practices. Allegations range from “phantom billing” (billing for medical services not actually provided to patients) to offering and accepting illegal kickbacks and referral fees. Many times, investigations are set off by “anomalies” in providers’ billing data. Often, without consideration for how one provider’s practice may be very different from another. Providers who do their best to comply with regulations can still find themselves accused of billing fraud.

Facing a federal healthcare fraud investigation is a significant event. The investigation alone can trigger licensing action by the Maryland Board of Physicians, and providers found liable for overbilling Medicare, Medicaid, Tricare, or another health benefit program can face civil or criminal charges. With penalties including hefty fines, recoupments, treble (triple) costs, and loss of federal program eligibility – not to mention prison time in criminal cases – it is essential to present an effective defense during the investigative process.

A Nationally-Recognized Healthcare Fraud Defense Team Serving Baltimore, MD

At Oberheiden, P.C., our Baltimore healthcare fraud defense attorneys have well over 100 years of combined experience in federal healthcare fraud matters. Many of our attorneys are former senior healthcare fraud prosecutors with the U.S. Department of Justice (DOJ) who have handled thousands of federal fraud investigations. Led by Partner Dr. Nick Oberheiden, our healthcare fraud defense team has a significant record in high-stakes federal matters.

“Our experience with [Oberheiden, P.C.] was overwhelmingly positive! We recently brought a range of complex legal issues to the table, which they responded to with a systematic, prudent approach. Throughout our work together, Oberheiden, P.C. served as an invaluable source of practical guidance and legal leadership. We would recommend them highly and without reservation to anyone.” – Healthcare Provider, Firm Client

“Our companies have worked with firms all over the country within various specialties and now use [Oberheiden, P.C.] almost exclusively. Nick represented our companies in some federal law investigations. His guidance and expertise allowed us to continue to concentrate on our core business as he dealt with the complex legal issues.” – Healthcare Provider, Firm Client

Put our highly experienced team on your side

Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd

Former DOJ Trial Attorney

Partner

Brian J. Kuester

Former U.S. Attorney

Hon. Kevin McCarthy

55th Speaker, U.S. House of Representatives (ret.)

Government Consultant

Mike Pompeo

Of Counsel

Former U.S. Secretary of State

John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara

Federal Appeals Attorney

Nicholas B. Johnson

Former Prosecutor

Roger Bach

Former Special Agent (DOJ)

Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen

Former Supervisory Special Agent (FBI)

Experienced Legal Representation for Baltimore-Area Providers Facing Federal Healthcare Fraud Investigations

Our Baltimore, Maryland healthcare fraud defense lawyers represent medical providers and healthcare companies in downtown Baltimore and the surrounding areas. Oberheiden, P.C. is known for reliability, superior communication and a supportive attorney client relationship. This includes areas surrounding Baltimore like:

• Catonsville,
• Columbia,
• Hunt Valley,
• Lutherville,
• Reisterstown, and
• Anne Arundel County.

Our experience is shown in our success defending individuals and organizations in investigations and prosecutions in matters such as those described below. Being found guilty of healthcare fraud can lead to exclusion from federal healthcare programs, along with severe financial penalties and possible imprisonment.

Double-Billing

Double-billing includes billing the same service or item multiple times to a single healthcare benefit program. Billing the same service or item to multiple programs. Or, billing the same service or item to a healthcare benefit program and a private insurer. Allegations of double billing can be a misunderstanding of providers’ billing records as well as a variety of unintended mistakes. Mixing up patient records, clerical errors, and other administrative mistakes are all common factors. Avoiding or mitigating liability requires first-rate knowledge of the specific issue(s) involved.

Billing for Medically-Unnecessary Services

Federal healthcare benefit program billing rules only allow payments for “medically necessary” services, supplies, and equipment. In this context, medical necessity is determined by the government, not the needs of the patient. Providers who bill for services deemed medically unneeded can face recoupments, denial of payments, pre-payment review, and other penalties.

Billing for Services Not Provided (“Phantom Billing”)

Billing for medical services not provided is another form of fraud often the result of unintended mistakes. The intentional submission of false and fraudulent claims is a very real issue costing the government billions of dollars every year. Many cases of “phantom billing”, however, do not rise to the level of criminal healthcare fraud.

Billing for Non-Allowable Costs

Certain costs are not eligible for reimbursement through Medicare, Medicaid, and Tricare. One category of costs that gets attention from federal authorities is operational expenses. Medical equipment and certain other items purchased for office use are eligible for federal funds, but billing other non-patient-related costs can lead to allegations of Medicaid fraud, Medicare fraud, and Tricare fraud.

Billing for Unlicensed and Excluded Service Providers

Services provided by unlicensed practitioners are typically not eligible for reimbursement. This includes medical treatment, physical therapy, and psychological counseling. Providers can also be held liable for billing services by practitioners who are excluded from federal and other healthcare benefit programs.

Non-Compliance with Conditions

All federal program claims must be submitted in compliance with the applicable program conditions. For Medicare, this means strictly adhering to the terms of the Medicare Claims Processing Manual. Non-compliance with conditions is grounds for denial of payment. For fraudulent claims already paid, it is grounds for imposition of fines and other penalties.

Unbundling

Under federal program billing rules, some related services and items must be billed at discounted “bundled” rates. Billing these services and items at their stand-alone rates (referred to as “unbundling”), whether intentionally or unintentionally, can lead to allegations of federal healthcare fraud.

Up-Coding and Use of Incorrect Billing Code

Up-coding is billing a service or item at a higher rate than the one allowed by program regulations. For example, billing a brief consultation with a nurse as a full in-office exam done by a physician. Like other forms of billing and coding fraud, up-coding can be an honest human error as well.

The same goes for use of the incorrect billing code not specifically within the context of up-coding. If a healthcare business or medical practice bills a service at the incorrect rate, it may warrant a refund, but it does not always reflect willful healthcare fraud deserving of criminal prosecution.

Kickbacks, Bribes, and Referral Fees

The federal Anti-Kickback Statute makes it illegal to offer, solicit, pay, or accept, “any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind,” in connection with referrals for federally reimbursed healthcare services, supplies, equipment, or facility rentals. The Anti-Kickback Statute’s prohibitions are broad, although they are also curbed through a laundry list of statutory and regulatory “safe harbors.” Forms of compensation prohibited under the Anti-Kickback Statute include:

• Cash payments;
• Discounts for services, supplies, or equipment;
• Free or below fair market value clinical space, equipment, or staff;
• In-kind gifts (such as airplane tickets);
• Payments to family members;
• Marketing commissions;

A Baltimore healthcare fraud defense attorney routinely represent clients in Anti-Kickback Statute investigations. We have significant experience showing that our clients’ transactions qualify for safe harbor protection.

Physician “Self-Referrals”

The federal Stark Law prohibits transactions commonly referred to as physician “self-referrals.” This includes direct or indirect compensation or investment of federal program funds paid to or received from an entity that offers “designated health services.” Designated health services under the Stark Law include:

• Clinical laboratory services,
• DME and medical supplies,
• Home health services,
• Imaging,
• Inpatient and outpatient hospital services,
• Outpatient pathology,
• Outpatient prescriptions,
• Parenteral and enteral nutrients, equipment, and supplies,
• Physical therapy,
• Prosthetics, orthotics, and related supplies,
• Radiology and radiological therapy.

Falsifying Test Results and Providing Improper or Unnecessary Treatment

Falsifying test results to submit more costly claims is a commonly alleged form of fraud. Sometimes, federal agents allege providers not only falsify test results, but provide improper or unneeded treatment based on the fraudulent results. Allegations of falsifying test results must be taken seriously. Healthcare fraud resulting in patient harm carries additional criminal penalties.

Falsifying Patient Treatment Records

Falsifying patient treatment records can be prosecuted as a form of up-coding. It’s a clear violation of the False Claims Act. However, not all providers accused of falsifying patient records have actually done so. These cases are often far more complex than they first appear. Providers must convince investigating authorities that their assumptions are misguided. In some cases, single incidents of failure to maintain accurate treatment records can lead to fraud accusations. Avoiding liability is a matter of proving the sample records are not typical of the provider’s record keeping practices in general.

Prescription Drug Diversion, Drug Shorting, and Refill Schemes

In 2017, the DOJ announced the formation of a new Opioid Fraud and Abuse Detection Unit. There are 12 regional task forces around the country. One task force was assigned to Maryland. The units investigate and prosecute providers who are believed to illegally prescribe, dispense, and administer opioid medications. One of the Unit’s top priorities is to prevent and penalize the practice of prescription drug diversion. Diversion is providing opioid medications to those who have not been properly prescribed them. Drug shorting and refill schemes are other forms of drug diversion alleged against physicians, pharmacists, clinics, and other providers.

Compound Pharmacy Fraud

Compound pharmacies in Baltimore are targets of federal healthcare fraud investigations as well. Referral fees, dispensing unnecessary medications, and billing for non-allowed ingredients are allegations in compound pharmacy fraud investigations.

Other Forms of Prescription Drug Fraud

Investigations of providers’ prescription drug practices often involve a range of other accusations. Common allegations in prescription drug fraud cases include:

• Falsifying and forging prescriptions;
• Illegally importing prescription medications or ingredients;
• Inaccurately reporting test results in order to issue fraudulent prescriptions;
• Prescribing medications without conducting in-person exams;
• Prescribing more medication than is necessary or dispensing more medication than was prescribed;

Home Health Agency and Hospice Fraud;

Home health agencies and hospices in Baltimore must comply with regulations beyond those applied to other healthcare professionals. Included is the requirement to have physician certifications and, for hospices, to have election statements signed by patients. Physician certification, and election statement fraud allegations are both common. Home health agencies and hospices must demonstrate they have policies and procedures to prevent unlawful billings.

Our Baltimore Healthcare Fraud Defense Lawyers Answer Providers’ FAQs

If your business or practice is under investigation by the DEA, DOJ, FBI, OIG, CMS, or another federal agency or task force, it’s important to seek immediate legal counsel. You can contact Oberheiden, P.C. 24/7, and we will arrange for you to meet with a Baltimore healthcare fraud defense lawyer as soon as possible.

Contact Oberheiden, P.C.

To schedule a free initial consultation with our healthcare fraud defense team, please call 888-680-1745 or request a case assessment online now. Our Baltimore healthcare fraud defense attorneys are available 24/7, and if we cannot take your call immediately we will respond as soon as possible.

Additional Pages for Baltimore, Maryland

• Baltimore federal appeals

• Baltimore white collar crimes