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Plano Healthcare Fraud

Knowledgeable Healthcare Fraud Defense Lawyers Representing Medical Professionals and Businesses in Plan

Plano address – by appointment only:
5465 Legacy Drive Suite 650
Plano, TX 75024
888-680-1745

If you are a physician or other medical provider in Plano or the surrounding area, the potential of finding your practice or business under federal investigation is high. Officials at the local, state, and federal level pursue actions for reimbursement costs of prescription drug abuse. The United States Department of Justice (DOJ) and other federal agencies pursue whistleblower actions actions based on accusations of defrauding public health programs. The focus on pursuing civil and criminal sanctions against those supposedly engaged in healthcare fraud threatens to implicate providers of medical care and services for honest mistakes.

Do you operate a medical practice or business providing services in the health sector? The mere thought of a federal investigation, grand jury indictment, civil qui tam action, or criminal prosecution can be frightening. We recognize your professional and business reputation is a valuable asset that can be damaged by actions from government regulators.

Experienced Former Federal Prosecutors Advocating for Healthcare Professionals in North Texas

Our local North Texas healthcare fraud defense attorneys at Oberheiden, P.C. know the career of any medical provider can suffer damage by the impact of allegations of fraud or misconduct. We understand the threat to the reputation of your medical practice or health business. That’s why our law firm focuses on quashing legal actions against our clients before they get started. Our law firm has a reputation for aggressive defense and giving sound legal advice to our clients. When retained early in the process, we strive to keep you from facing formal charges in federal court. Health industry providers and businesses choose Oberheiden, P.C. because of our experience and proven results.

  • Former Justice Department Lawyers
  • Former Federal Healthcare Fraud Prosecutors from the U.S. Attorney’s Office
  • Significant Experience with Healthcare Fraud Cases in Collin County and the Eastern District of Texas
  • Locally Available, Including on Weekends

The legal team at Oberheiden, P.C. was built with one objective in mind–helping professionals like you. We are a North Dallas law firm of former DOJ lawyers. We focus on healthcare fraud and other crimes in the medical sector. Our law firm has a national reputation in health fraud defense by keeping investigations from going before a grand jury.

Plano Healthcare Fraud

Overview of the Medicaid and Medicare Fraud Investigation Process

Federal agencies partner with state and local law enforcement to uncover and punish healthcare fraud schemes. Tactics often include the use of confidential informants, such as ex-employees, and others with knowledge of the medical practice. These individuals facilitate the investigation in pursuit of criminal charges. The intense attention along with rewards offered to whistleblowers often results in simple negligence or incidental errors reported as fraud.

If you frequently bill Medicare/Medicaid, you know the procedures are complicated. Because of these complexities, coding errors and other unintended mistakes occur. Fraud prosecutions under federal statutes forces health professionals to endure intrusive investigations. During a Medicaid/Medicare audit, you need an attorney with knowledge of the Centers for Medicare and Medicaid Services (CMS) regulations. In addition, experience handling cases involving state and federal fraud laws is vital. Health fraud allegations may target many types of conduct, including the following:

  • Billing for ghost patients
  • Illegal kickbacks
  • Billing services individually when they should be grouped under a code (Unbundling)
  • Medical procedures or prescriptions that are not medically necessary
  • Billing for a more expensive service than that performed (Up coding)
  • Submitting false claims to CMS
  • Billing for services from excluded providers
  • Performing excessive services or procedures (Overutilization)
  • Giving false statements on applications or contracts for participation in Medicaid/Medicare
  • Billing for equipment or services not provided

Our experienced Plano healthcare audit lawyers recognize that CMS has more contractors reviewing provider claims now than in recent years. If you receive notice of an alleged “overpayment” from a CMS contractor, the experience can be confusing. Our Plano law firm is driven to represent health professionals facing federal actions. Many Medicaid audits result in enormous recoupment demands. The results of noncompliance with a recoupment demand can include penalties, fines, and interest. More importantly, the audit could result in a state or federal case and criminal liability.

Our Plano health audit lawyers take an aggressive approach to ensure that auditors stay within the confines of their CMS mandate. We also check to prevent false accusations by the government. Our experts in health audits thoroughly examine audit methods and conclusions. We work to prove our clients’ compliance and expose errors in the audit.

Recovery Audit Contractors (RACs)

RAC audits analyze claims that are submitted to identify under and overpayments. Companies performing these audits are usually compensated on a contingency-fee basis. Therefore, they are motivated to find overpayments. This form of audit has been expanded to Medicare Advantage (Part C), and Prescription Drug Plans (Part D).

Comprehensive Error Rate Testing Program (CERTs)

The primary focus of CERT is to determine a general error rate. That information is then forwarded to the carrier or a Medicare Administrative Contractor (MAC). The MAC will use the information to pursue recovery of overpayments.

Zone Program Integrity Contractors (ZPICs)

MAC auditors primarily focus on uncovering and preventing errors. However, ZPIC audits focus on potential healthcare fraud. Providers are required to submit medical documentation to substantiate claims. Payment is frequently held up until the completion of an appeals process. Many ZPIC audits are triggered by referrals from RAC and MAC contractors. ZPIC contractors might receive leads triggering closer scrutiny through a variety of sources such as:

Medicare Administration Contractors (MACs)

These contractors are used for a range of purposes. One example is handling billing errors when services are improperly coded or not covered. MACs also identify “outliers” based on analysis of provider data. Based on what is found, these contractors often schedule audits of flagged providers. Auditors modify or deny payment if they deem the claims not medically necessary or reasonable. The reviewer also looks for payments made for services not provided by the physician or business submitting the claim.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd
Lynette S. Byrd

Former DOJ Trial Attorney

Partner

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)

Federal Investigations and Prosecutions in Plano & Collin County

Federal healthcare fraud charges leading to civil or criminal liability may originate from a wide array of agencies that include the:

  • United States Department of Health and Human Services Office of the Inspector General, United States Department of Justice,
  • Drug Enforcement Administration,
  • Department of Labor Employee Benefits Security Administration,
  • United States Postal Service Office of the Inspector General,
  • Department of Defense (Tricare),
  • Criminal Investigations Division Internal Revenue Service, and
  • Federal Bureau of Investigation.

Our dedicated and proven Plano healthcare fraud attorneys have the expertise to defend physicians and health businesses under federal investigation, grand jury, prosecution, or subpoena. We have a successful history of helping medical professionals and healthcare companies avoid civil and criminal penalties.

The dizzying number of federal agencies that might be involved in a federal investigation for health fraud violations is matched by the many legal grounds for pursuing healthcare entities and individuals. Some of the most common tools of regulatory enforcement include:

False Claims Act (31 U.S.C. 3720-3733)

The federal False Claims Act forbids filing a false claim to a benefit program like Medicaid, Medicare, or Tricare. Physician practice groups and other health providers can be subject to civil damages and penalties under the federal statute. For example, Olympus Corp. was forced to pay $310.8 million to settle a claim under the law several years ago. Healthcare related billing practices that involve Medicare and that are forbidden by the FCA include the following:

  • Causing a false or fraudulent claim to be presented
  • Conspiring with others to induce the federal government to pay a false claim
  • Presenting a fraudulent or false claim
  • Using or causing to be used a false statement or false documentation to obtain federal payment of a claim

The financial penalties under the FCA can’t be overstated. The Department of Justice can seek treble damages, so $200,000 in false claim results in liability that can be $600,000. The law also compels the judge to impose a civil penalty for each false claim. The amount of this civil fine per violation recently was raised from $10,781 to $21,563. Putting these penalties in perspective, fifty individual false Medicare claims could cost a health professional from between $539,050 and $1,078,150 in penalties.

Stark Law (42 U.S.C. 1395nn) & Anti-Kickback Statute (42 U.S.C. 1320a-7b)

The physician self-referral laws Stark Law and Anti-Kickback Statute (AKS), target medical entities and doctors engaged in agreements that could generate medical referrals, or the provision of health services. The referrals being for reasons of financial gain rather than therapeutic value. The laws impose harsh civil and criminal penalties for practices related to Medicaid and Medicare reimbursed healthcare benefit programs.

The Stark Law prohibits payments to doctors who refer patients to medical providers with whom the physician has a financial relationship or interest. While a violation of the Stark Law can result in significant fines, our Plano Stark law defense attorneys often successfully apply exceptions and safe harbor provisions to defend clients.

Similarly, the AKS imposes criminal penalties for willfully and knowingly soliciting, offering, receiving, or paying for business billed to Medicare and Medicaid. The employment relationship exception also applies to the AKS. Our lawyers are thoroughly versed in all relevant safe harbors and exceptions. For example, when a “bona fide” employment relationship exists between the physician and the entity or individual to whom the patient was referred, a defense may exist if the employer pays fair market compensation.

Medicaid Fraud (18 U.S.C. 1347)

The healthcare fraud law prohibits knowingly and willingly executing an artifice or scheme to obtain money or property using false representations, promises, or pretenses from a health benefit program. A violation can result in 10 years in federal prison and a fine, or both.

Frequently Asked Questions from Medical Industry Providers Targeted for Healthcare Fraud Investigations and Prosecutions in Texas

Q: Can assets of a physician be seized based on an allegation of healthcare billing fraud?

 

When a doctor or other healthcare provider or entity is arrested for fraud under a federal statute, such as the Stark Law or the Anti-Kickback Statute, the government might freeze the individual’s or company’s bank accounts. The government takes this action in order to seize the funds if they are the fruits of unlawful activity. However, the more damaging effect is that the loss of access to these funds imposes financial pressure on the accused. This makes them more likely to accept an unfavorable guilty plea. Even if the government cannot prove the assets frozen were profits of criminal activity, the state will seek to have equivalent funds seized under a “substitute asset” theory. The government also can seize property such as real estate, vehicles, jewelry, etc. Call Oberheiden, P.C. today if you have questions about how to legally avoid effects of forfeiture or seizure in a healthcare fraud investigation.

Q: What types of cases do you handle against healthcare professionals?

 

Our healthcare fraud attorneys in Plano and throughout Northern Texas provide effective defense in cases of health professionals facing allegations including, but are not limited to the following:

  • Taking part in financial relationships that constitute an impermissible conflict of interest
  • Receiving or providing financial inducements like kickbacks
  • Upcoding
  • Billing for medical services not furnished
  • Unlawful marketing of drugs and medical devices
  • Double billing for legal services
  • Making false claims to government insurance benefit plans
  • Billing for medical services that are not medically necessary

Q: What should I do if I am under investigation by the federal government?

 

Prepare for a potential federal investigation or a Medicare audit BEFORE you are a target. Seek compliance advice from an experienced Plano healthcare fraud attorney. Our team works with a number of industry experts. This allows us to review your billings and assist you in identifying and clearing errors. Then, we will help develop procedures to promote compliance in the future. If you are contacted about an audit or investigation, seek prompt legal advice from an experienced healthcare fraud defense attorney as soon as possible.

Q: What types of providers and companies get investigated for improper billing and other forms of healthcare fraud?

 

If you are a physician or virtually any business engaged in the health industry, you can be a target of audit or federal investigation. Some of the parties that have faced health fraud allegations include:

  • Physician Practice Groups
  • Cardiologists
  • Mental Health Groups
  • Psychiatrists and Psychologists
  • Laboratories
  • Home Health Agencies
  • Hospice Agencies
  • Physical Therapy Clinics
  • Drug Treatment Centers
  • Imaging Centers
  • Nursing Homes
  • Equipment Vendors
  • Pharmacies
  • Healthcare Marketers

These are just a few examples of individuals and entities especially vulnerable to health fraud accusations.

Speak with a Qualified Plano Healthcare Fraud Lawyer Today

Our North Texas healthcare fraud defense law firm works diligently to protect our clients’ professional practices and to shield our clients from civil or criminal liability. If you wish to speak with a member of our team of attorneys with experience that includes many trials, we invite you to call us at 888-680-1745 or request a free case evaluation online now.

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