Medicare Compliance Consultant - Federal Lawyer
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Medicare Compliance Consultant

Healthcare providers who bill Medicare must deal with an extremely burdensome and bureaucratic system. However, a provider’s failure to comply with these cumbersome—yet important—guidelines can result in an audit, which not only disrupts business but can also result in a recoupment, civil monetary penalties, exclusion from Medicare, and even criminal enforcement actions. Thus, all healthcare providers must implement a comprehensive compliance policy to guide employees and management in their daily business.

At Oberheiden, P.C., we are nationally recognized as a preeminent Medicare compliance law firm. Our team of dedicated Medicare compliance consultants commands an unrivaled knowledge of both the Medicare regulations as well as the healthcare industry as a whole. We will work closely with your practice or business to ensure the development of an effective compliance program that not only establishes clear guidance but can also protect you and your practice from liability in the event of an audit or investigation.

Does Your Practice Need a Medicare Compliance Program?

If you own or operate a healthcare business of any kind, it is imperative that you have a Medicare compliance program in place. Compliance programs serve two main goals. First, having a compliance program provides all employees with the information they need to avoid conduct that may raise the suspicion of auditors and investigators. In this way, a compliance program reduces the chance of an audit or investigation by ensuring that a practice complies with the complex Medicare billing and coding regulations.

The second benefit of a Medicare compliance program is that it can serve as a shield in the event of an unsuspected audit or investigation. When investigators open up a Medicare fraud case, one of the first things they look for is whether the practice has a compliance program on the books. Investigators are much more likely to consider an error—or series of errors—a misunderstanding if a practice has an effective Medicare compliance program.

Of course, the mere existence of a compliance program isn’t necessarily going to absolve providers of responsibility in the event auditors or investigators identify Medicare billing and coding errors; a practice must make a good-faith effort to follow the program.

What Mistakes Are Auditors and Investigators Looking for?

Medicare fraud and abuse are a major concern for the federal government. During challenging economic times like the ones we’re currently experiencing, practitioners face heightened scrutiny due to the fact that Medicare fraud and abuse are considered to be taking money out of taxpayers’ pockets. As a result, in recent years, federal authorities have increased the number of Medicare fraud claims. In fact, in 2020 alone, the federal government opened 1,148 new criminal fraud investigations, recouping more than $1.8 billion in healthcare fraud judgments and settlements.

Some of the most common errors that can lead to an audit or investigation include:

  • Billing for equipment or services that were not provided to the patient;
  • Billing for services that are not covered;
  • Clustering; and
  • Double-billing,
  • Failure to use coding modifiers;
  • Misusing provider identification numbers, which results in improper billing
  • Submitting claims for equipment, supplies or services that are not medically necessary
  • Unbundling or billing for each component of the service rather than using an all-inclusive code;
  • Upcoding the level of service provided.

Given the complexity of the Medicare billing and coding regulations, it is all but impossible for a practice to bill with 100% accuracy. However, absent a Medicare compliance program, a practice may find itself scrambling to prove a series of errors were inadvertent.

What Goes into a Medicare Compliance Program?

The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) expects all providers, including doctors, practice groups, hospitals, hospice care facilities, pharmacies and DME manufacturers, to develop compliance programs. In doing its part, the HHS-OIG provides some basic guidance for providers in terms of what should be included in a compliance program. For example, according to the most recently released guidance, the HHS-OIG expects a Medicare compliance program to do the following:

  • Implement written policies, procedures and standards of conduct
  • Designate a compliance officer and compliance committee
  • Conduct effective training and education among employees
  • Maintain open and effective lines of communication
  • Enforce standards through well-publicized disciplinary guidelines
  • Conduct internal monitoring and auditing
  • Respond promptly to detected offenses and develop a corrective action plan

Of course, not all healthcare providers face the same compliance risks, and what’s expected of a provider depends on many variables. For example, the HHS-OIG acknowledges that individual doctors and small practice groups will not have the time or resources that a large hospital will have. Thus, the HHS-OIG expects a less robust compliance program from these providers.

The bottom line is that there is not a one-size-fits-all compliance program; every provider should ensure that their Medicare compliance program is catered to their practice’s unique compliance risks.

What Is at Stake in a Medicare Fraud Investigation?

Healthcare fraud can result in civil or criminal liability, depending on the nature of the violation. For example, in 2020, federal prosecutors obtained criminal convictions against 440 defendants for healthcare fraud. That same year, the Department of Justice opened more than 1,075 new civil healthcare fraud and abuse cases. As a result, the U.S. Health and Human Services Office of Inspector General excluded over 2,100 providers from participating in Medicare and other federally funded programs.

Whether a Medicare violation results in civil or criminal liability depends on the specific allegations. For example, under the False Claims Act, the government can seek to hold providers civilly liable for any conduct that results that deprives the government of resources it is entitled to. This is regardless of whether a provider had an intention to defraud the government; all the government needs to prove is that you knowingly submitted the claim (or caused the claim to be submitted) that contained the errors. However, if the government determines a provider acted with an intent to defraud, it can bring criminal charges under 18 U.S.C. 1347.

How Can the Medicare Compliance Consultants at Oberheiden, P.C. Help?

Developing an effective Medicare compliance program is a task that requires advanced knowledge of Medicare regulations as well as what goes into an effective compliance program. At Oberheiden, P.C., our federal Medicare fraud defense attorneys have notable experience handling all types of healthcare fraud cases. In recent years, Oberheiden, P.C. has handled many federal jury trials and resolved more than 2,000 healthcare fraud cases without the need for a trial. Additionally, many of our senior attorneys formerly prosecuted and investigated healthcare fraud on behalf of the federal government. Collectively, this vast experience and depth of knowledge gives Oberheiden, P.C. unique insight into what auditors and investigators want to see in a Medicare compliance program.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



Lynette S. Byrd
Lynette S. Byrd

Former DOJ Trial Attorney


Brian J. Kuester
Brian J. Kuester

Former U.S. Attorney

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney

Local Counsel

John W. Sellers
John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara
Linda Julin McNamara

Federal Appeals Attorney

Aaron L. Wiley
Aaron L. Wiley

Former DOJ attorney

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (DOJ)

Chris Quick
Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow
Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

Contact a Knowledgeable Medicare Compliance Consultant at Oberheiden, P.C. Today

A compliance program will help your organization avoid inadvertent violations. However, it is common for even the most well-intentioned organization to inadvertently engage in conduct that may constitute Medicare fraud or abuse. In these situations, having a compliance program can show investigators that your organization takes compliance seriously and may assist in wrapping up an investigation without the government formally filing charges. However, if you are currently facing a Medicare audit or investigation and worry about your level of compliance, there may still be steps you can take to mitigate your risk. In these situations, it is especially important to reach out to an experienced Medicare compliance consultant at Oberheiden, P.C. to identify what you can do to lessen your risk exposure. To learn more, and to schedule a free consultation with a Medicare compliance consultant, give Oberheiden, P.C. a call at 1-888-680-1745. You can also connect with us through our online contact form and one of our Medicare compliance consultants will be in touch shortly.

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