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How Doctors Get in Trouble for Healthcare Billing Fraud

Don’t Risk Your License.
Get the Help of Former DOJ Attorneys at Oberheiden P.C.

Obviously, no doctor handles his own billing. Nonetheless, how is it possible that dozens of physicians, psychiatrists, and dentists have been convicted of healthcare billing fraud in the last two years alone? More so, providers across the country have entered civil settlements with the United States government admitting healthcare fraud and accepting permanent exclusion from CMS—in exchange for not going to federal prison. The answer is simple. Under current Justice Department policies, doctors can be arrested, indicted, and prosecuted for healthcare billing fraud if they overbill, typically as so-called “outliers.”

  • Government Data Analysis May Consider You an Outlier
  • Former Employees May Report You Causing Costly Investigations
  • An Ungrateful Patient May Threaten to “Turn You In”
  • Doctors Get Caught Up in Lawsuits, Divorces, and Board Investigations

Oberheiden P.C. is known for its forceful defense of physicians’ licenses and reputations. Many of our attorneys come from leading positions within the Justice Department where they oversaw civil and criminal healthcare fraud and healthcare billing investigations—an insight that now benefits clients of Oberheiden P.C. across the United States. Get the trusted advice of Oberheiden P.C. senior attorneys.

Are You an Outlier? Do You Overbill or Upcode?

Current targets of federal fraud investigations are dentists, cardiologists, internal medicine specialists, psychologists, psychiatrists, and other doctors that submit more claims, ask for higher reimbursement, and represent unrealistic billing claims. Real-life case examples include doctors that routinely bill Level 4 office visits, physicians that bill Medicare when out-of-town, busy practices that see more than twenty patients a day, psychiatrists that bill for in-office visits for phone consultations, or dentists that bill for expensive procedures in a disproportionate high number of cases.

  • Are You More Successful Than Other Doctors in Your Area?
  • Do You See More Patients Than the Doctor Next Door?
  • Is Your Billing In-House? Does Your Billing Team Have Certified Coders?
  • Under Your Billing Contracts, Who Is Responsible for Billing Errors?
  • Have You Received Audit Letters Using the Word “Outlier?”
  • Have You Been Under Audits for a Particular Code?
  • Have Federal Agents or CMS Investigators Tried to Interview You?
  • Is Your Practice Currently Under Audit?
  • Do You Want to Shift Billing and Coding Responsibilities to Someone Else?
  • Are You Dealing with Disgruntled Former Employees?
  • Has a Patient Threatened to “Turn You in?”
  • Are You in a Lawsuit, Divorce, or Board Investigation?
  • Do You Need an Attorney?
  • Ready for Oberheiden P.C.?

Sadly, all the government does is compare one doctor in a particular zip code to another doctor in that area. Once the computer comparison evidences discrepancies, the case is assigned to a fraud specialist, then to a fraud investigator, and, in a worst-case scenario, then handed over to the Federal Bureau of Investigation—and you are then in the middle of a healthcare investigation.

What Is Healthcare Billing Fraud?

Healthcare billing fraud is a federal crime that is regulated in 18 U.S.C. 1347. Importantly, under current Justice Department policies, it is irrelevant whether the underlying claims were submitted to a federal program like Medicare or whether the alleged victim is a private health insurance carrier like United Healthcare. In both scenarios, the U.S. Justice Department claims jurisdiction under general healthcare fraud statutes, the federal Travel Act, or by way of wire and mail fraud— two federal felonies with a punishment range of up to twenty years’ incarceration per single claim. In general terms, a physician is guilty of healthcare billing fraud if the government can prove beyond a reasonable doubt that the following elements are met:

(1) The defendant knowingly and willfully executed or attempted to execute a scheme to defraud a healthcare benefit program or obtain money or property from a health care benefit program by means of false or fraudulent pretenses, representations, or promises;

(2) The defendant executed or attempted to execute the scheme or plan in connection with the delivery or payment of benefits, items or services under the healthcare benefit program; and

(3) The defendant acted with the intent to defraud the health care benefit program.

Billing violations are typically investigated by federal law enforcement agencies such as the Federal Bureau of Investigation (FBI), the Office of Inspector General (OIG), the Medicaid Fraud Control Unit (MFCU), and prosecuted by Assistant United States Attorneys from one of the country’s 95 local U.S. Attorney’s Offices. Don’t wait for them to make contact with you. Call Oberheiden P.C. right away to secure your rights!

Why Are You Responsible for the Billing Mistakes of Others?

If you as a physician don’t bill, how then can you be held civilly or criminally responsible for coding and billing errors? The government takes the position that because you as the practice owner benefit from untrue billing and thus higher reimbursements, you are the one to be liable. In other words, instead of being required to prove specific intent that you willfully violated healthcare laws through false billing, the intent element is assumed through the fact that you are the financial benefiter. In other words, your management structure with you on top of the pyramid can be enough to hold you responsible—even if you yourself never get involved with billing and coding.

Do You Want to Shift Billing and Coding Responsibilities to Someone Else?

The consequence of just described organizational and managerial liability must be: isolate yourself from liability! Don’t be the one losing your license, your career, and possibly your freedom. Ask Oberheiden P.C. attorneys how to shield yourself from government investigations, audits, and culpability.

  1. Enter a Billing Contract that Exonerates You from Mistakes
  2. Get the Oberheiden P.C. Compliance Structure to Protect Your Practice
  3. Call Experienced Attorneys the Moment You Receive an Audit Letter
  4. Don’t Underestimate the Threat of Complaints Against You
  5. Don’t Expose Yourself in Lawsuits or Depositions
  6. Don’t Handle Yourself, Delegate Responsibility Through Agreements!

Call Attorney Dr. Nick Oberheiden Today and Get a Free and Confidential Consultation!

Call Oberheiden, P.C. today at (214) 692 2171, including on weekends, or inquire online. Consultations are free and confidential.

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