Columbia, Missouri Healthcare Fraud Defense Attorneys
Columbia Healthcare Defense
Team Lead
Contact Nick4818 Washington Blvd.
St. Louis, MO 63108
314-309-3313
Federal investigators have been prioritizing healthcare fraud investigations for several years, now, largely due to political pressure to rein in the exploding costs of healthcare by reducing fraud, waste, and other inefficiencies. However, those investigations can put healthcare providers in a difficult position. You need legal representation with the skills and knowledge to help protect you from an investigation before you lose your business, and maybe your freedom. A Columbia, Missouri healthcare fraud defense attorney is only a call away. Even innocent medical professionals and businesses suffer from the increased scrutiny, as the higher costs of compliance and of defending against allegations of wrongdoing can undercut their bottom line which then, ironically, increases the costs of healthcare for the patients who need it.
The healthcare fraud defense lawyers at the national law firm Oberheiden P.C. have represented numerous healthcare providers in the Columbia, Missouri, area. Having a skilled Columbia, Missouri healthcare fraud defense attorney is highly beneficial in constructing a robust strategy to protect clients’ rights during these investigations. Using aggressive advocacy and savvy defense strategies, we have been able to secure numerous satisfactory outcomes for our clients, including case dismissals and even dropped investigations.
Civil Healthcare Fraud Claims Do Not Require Intentional Conduct
The most important thing that healthcare providers in Columbia, Missouri, need to know about healthcare fraud law is that intent is not required for civil claims of fraud. Many healthcare providers and professionals are under the impression that fraud requires deliberate and intentional conduct, but that is not quite right: A specific intent to defraud is only required for criminal allegations of healthcare fraud.
There are two other ways for law enforcement agents and other investigators to pursue suspected healthcare fraud: Civil claims and administrative cases.
The Three Ways of Pursuing Healthcare Fraud Cases
Healthcare fraud can be pursued by investigators in three different ways:
- Criminal charges
- Civil lawsuits
- Administrative cases
The penalties decrease with each one, though the standard of proof also decreases as you go down the list.
Even though the penalties decrease, they are never minor or trivial.
Criminal Cases of Healthcare Fraud
Criminal charges for healthcare fraud carry the highest penalties, but also have the highest standard of proof for law enforcement and prosecutors to meet. Healthcare fraud can be classified as felony offenses under Missouri state law. Convictions only happen if you are found guilty beyond a reasonable doubt, but the penalties that come with that conviction are extremely high. They include:
- Prison time
- Criminal fines
- Restitution payments or forfeiture
- Probation
- The numerous collateral consequences of having a criminal conviction on your record, like the potential for losing your medical license
Importantly, though, one of the things that prosecutors have to prove beyond a reasonable doubt in a criminal case of healthcare fraud is that you acted with the specific intent of defrauding a healthcare insurance program.
Civil Lawsuits
Civil claims for healthcare fraud only have to be proven by a preponderance of the evidence. However, the penalties for civil liability are lower, and do not include prison time or the collateral consequences that come with having a criminal record. With that said, though, the financial penalties of a civil judgment for healthcare fraud can be massive, and often include treble damages if the healthcare program that was defrauded was run by the government.
A key difference between civil and criminal cases for healthcare fraud is the level of intent required. Criminal cases require a showing of a specific intent to defraud an insurer. Civil cases generally only require proof that you knew you were filing a false claim for reimbursement.
Administrative Cases
Administrative cases for healthcare fraud do not go through court: Instead, they are handled internally by the insurer – often the Centers for Medicare and Medicaid (CMS) for government-funded programs or by investigators for private insurers. These agencies, however, can claw back any overcharges that they determine were the result of billing errors, even if those errors were accidental and completely unintentional. Worse, significant overcharges or repeatedly committing them can lead to program exclusion.
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)
There are Lots of Ways to Violate Healthcare Fraud Statutes
Broadly speaking, fraud is vaguely-defined by the laws that prohibit it. This is not a mistake. If the parameters of fraudulent conduct were concretely defined, then bad actors would come up with ways to deceive people out of their money or property without running afoul of the law.
For healthcare providers, though, this means that they can face scrutiny for a wide range of conduct that is not clearly illegal: What some providers may think of as a normal business practice, a jury may find to be deceptive.
When it comes to healthcare fraud, though, most of the forms of fraudulent conduct tend to fall into one of two categories:
- Fraudulent billing, or
- Kickbacks and self-referrals.
There are numerous federal laws that prohibit each type of fraud, with some supporting criminal charges.
Fraudulent Billing
The most common allegations of healthcare fraud revolve around fraudulent or erroneous billing that lead to overpayments to the healthcare providers that are making the claims for compensation.
There are numerous ways for healthcare providers to do this.
Upcoding is a common example. Each medical service or procedure has an associated code attached to it. Healthcare providers, however, can provide the patient with one medical procedure but then bill the patient’s insurance company for a similar, but more expensive one.
Unbundling is another example. Many medical procedures, particularly diagnostic tests, are billed together in a discounted package. An example of a bundled procedure could be a blood draw and subsequent testing for:
- Hepatitis
- Cholesterol
- Glucose
- Lymphoma
By unbundling these tests and billing for each one individually, though, healthcare providers can deceptively increase their profits.
When these fraudulent tactics are used to increase the payouts that doctors and other providers receive from a government-funded program, like Medicaid, Medicare, or Tricare, federal law enforcement may get involved and pursue criminal charges under the general healthcare fraud statute, 18 U.S.C. § 1347, or civil claims under the False Claims Act (31 U.S.C. §§ 3729 – 3733). The Medicare Fraud Strike Force plays a crucial role in combating these fraudulent billing practices by utilizing data analytics and well-funded investigators to pursue cases against healthcare providers suspected of fraud. These task forces exist across the United States.
Anti-Kickback and Self-Referral Laws
Another type of healthcare fraud has to do with patient referrals. Healthcare providers can commit fraud by accepting kickbacks for referring a patient to another provider, or by referring patients to other providers in which they have a financial interest. While there are numerous exceptions and other safe harbors that providers can use to insulate themselves from liability, making a mistake can lead to substantial amounts of liability and potentially even a felony offense under one of the following federal laws:
- Stark Law (42 U.S.C. § 1395nn)
- Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))
- Eliminating Kickbacks in Recovery Act (EKRA) (18 U.S.C. § 220)
Oberheiden P.C.: Healthcare Fraud Defense in Columbia, Missouri
Healthcare providers and professionals in Columbia, Missouri, are not immune from the uptick in the enforcement of federal healthcare fraud statutes. If you suspect that you or your healthcare business is under investigation for fraud, reach out to the Columbia, Missouri healthcare fraud defense attorneys at Oberheiden P.C. by contacting them online or calling their law offices at (888) 680-1745.
5 Frequently Asked Questions About Healthcare Fraud and Oberheiden P.C.
1. What Does it Mean to Be Excluded from a Healthcare Insurance Program?
One of the repercussions that you are likely to face if evidence ties you to healthcare fraud – even if it was accidental or erroneous – is program exclusion. Whether it is a private insurance company or a federally-funded healthcare insurer like Medicare or Medicaid, if you are found to have overbilled the program by enough money or to have overbilled them too frequently then you are likely to get cut off from the program.
Known as program exclusion, this can be a huge blow to the success of your healthcare business, as you will no longer be able to take patients who use that insurer.
Even if you are not cut off completely, the program is likely to place restrictions on your payment, such as by requiring pre-approval of all bills before they are paid out. This can slow down the payment process enough that it may not be worth it for you to continue with the program.
2. Can a Conviction for Healthcare Fraud Lead to Prison Time?
Criminal charges for healthcare fraud can lead to prison time if you are convicted. The general federal statute for healthcare fraud, 18 U.S.C. § 1347, carries up to 10 years in prison for a conviction.
Furthermore, many healthcare fraud allegations come with additional charges alongside them, such as mail or wire fraud, or conspiracy. These can drastically increase the sentence that you could face on conviction. This all means that you need to hire an experienced Columbia, Missouri healthcare fraud defense lawyer as soon as you know you have been accused of medical fraud.
3. What are Treble Damages?
Some antifraud statutes, including the federal False Claims Act, impose civil liability of three times the amount that was obtained through the fraudulent conduct. Known as treble damages, these can cripple even extremely successful healthcare providers in Columbia, Missouri. It is also important to be aware of the trend for law enforcement officials to use the possibility of treble damages as leverage to get healthcare fraud suspects to plead guilty to terms that are higher than might be warranted in order to avoid the imposition of treble damages.
4. Why Not Just Argue That I Did Not Intend to Commit Fraud?
A lack of a specific intent to defraud a health insurance program is a strong defense, but only against a criminal allegation of healthcare fraud. Civil or administrative claims do not require a showing of that level of intent, and it is not uncommon for criminal cases to get reduced to civil claims when prosecutors realize that they will struggle to prove intent. Therefore, relying exclusively on a lack of intent is unlikely to completely defend you against all possible allegations of healthcare fraud: In focusing on avoiding the prison time that comes with a criminal conviction, you may allow the crippling financial sanctions that come with civil or administrative claims to go unchallenged. A savvy Columbia, Missouri healthcare fraud defense lawyer from Oberheiden, P.C. can explain more about the strategies and tactics needed to win your case.
5. Why Doesn’t Oberheiden P.C. Call Itself the Best Healthcare Defense Firm in Columbia, Missouri?
We prefer to let our prior clients say these sorts of things about the legal representation that we can provide. Read their testimonials here.
Oberheiden P.C.: Healthcare Fraud Defense in Columbia, Missouri
Healthcare providers and professionals in Columbia, Missouri, are not immune from the uptick in the enforcement of federal healthcare fraud statutes. If you suspect that you or your healthcare business is under investigation for fraud, reach out to our Columbia, Missouri healthcare fraud defense lawyers by contacting them online or calling their law offices at (888) 680-1745.
