How Long Does a Medicaid Investigation Take? - Federal Lawyer
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How Long Does a Medicaid Investigation Take?

investigations

Medicaid investigations present substantial risks for participating healthcare providers, health care facilities and nursing homes, medical supply companies, and pharmacies. Knowing what to expect during the process is critical—as this is the only way to develop and execute a targeted and timely defense strategy.

One aspect of knowing what to expect during a Medicaid investigation is knowing how long the process will last. So, how long does a Medicaid investigation take?

The short answer is, “It depends.”

Broadly, a Medicaid investigation can last anywhere from several weeks to several months. But, Medicaid investigations often follow lengthy Medicaid audits; and, when an investigation leads to civil or criminal enforcement litigation, the overall timeline can easily stretch to a year or longer. For targeted healthcare providers and pharmacies, the key to keeping a Medicaid investigation as short as possible—and to securing as favorable an outcome as possible—is to take an informed and proactive approach focused on achieving a specific desired resolution.

Let’s unpack this a bit more.

What To Expect During a Medicaid Investigation

To begin, we’ll cover what health care providers can (and should) expect during a Medicaid investigation. These are high-risk governmental inquiries that can expose healthcare entities; pharmacies; and individual providers, pharmacists, and executives to substantial penalties. Medicaid fraud is a serious federal offense, and the U.S. Department of Justice (DOJ) does not hesitate to pursue criminal charges under the False Claims Act, federal healthcare fraud statute, and other applicable federal laws as warranted.

With these risks in mind, here is a brief overview of what to expect during a Medicaid investigation:

1. Initial Contact from the MFCU

In most cases, the initial contact during a Medicaid investigation comes from the state’s Medicaid Fraud Control Units (MFCU), which is a part of the state’s Attorney General office. MFCUs are state-level law enforcement authorities that receive federal funding to uncover all forms of Medicaid fraud. If you’ve been contacted by your state’s MFCU, you need to take this very seriously, and you should engage defense counsel as soon as possible.

2. Formal and Informal Requests for Information

When conducting Medicaid investigations, MFCUs can request information from targeted healthcare providers and pharmacies through several formal and informal means. Search warrants, subpoenas, target letters, requests for staff interviews, and other requests all pose different risks and present different considerations for formulating and submitting a response. While targeted healthcare providers and pharmacies must comply with all legally enforceable requests for information (and while doing so promptly can help shorten the duration of the investigative process), they also need to be extremely careful to avoid disclosing any potentially damaging information unnecessarily.

3. Involvement of the HHS OIG, DEA, and Other Federal Agencies

While Medicaid investigations typically start with an MFCU, it is not unusual for federal authorities to get involved. The U.S. Department of Health and Human Services’ Office of Inspector General (HHS OIG), Drug Enforcement Administration (DEA), and various other federal agencies routinely assist MFCUs with Medicaid investigations. Not only does federal involvement present additional risks, but it typically extends the timeline as well.

4. Strategic Information Sharing on Both Sides

As the target of a Medicaid investigation, it is critical to make strategic decisions about the information you share with the MFCU and any other investigating authorities. While disclosure of certain information may be required, you will almost certainly be asked for information that you are not required to disclose. Whether it makes sense to disclose information voluntarily depends on the specific facts and circumstances at the relevant time.

In this same vein, the MFCU and other investigating authorities will be making strategic decisions about the information they share with you as well. Remember, their goal isn’t just to conduct an investigation, but ultimately to prosecute for Medicaid fraud.

5. Settlement Negotiations (as Warranted)

While some Medicaid investigations lead to prosecution for Medicaid provider fraud, many are resolved via settlement. If it isn’t possible to avoid liability for Medicaid-related billing violations entirely, then settling could be the most advantageous approach in light of the circumstances at hand. If settling with the government makes sense, your defense counsel will help you make informed decisions about how and when to pursue a settlement while negotiating with the authorities on your behalf.

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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)

Factors that Will Influence the Duration of a Medicaid Investigation

With these major steps in the process in mind, we can now take a look at some of the factors that will influence the duration of a Medicaid investigation. Some of the key factors that will determine how long a Medicaid investigation takes include:

1. The Investigation’s Focus and Scope

The broader an investigation’s focus and scope, the longer the investigation is likely to take. When facing a Medicaid investigation, discerning the specific risks involved is a key first step toward executing an effective defense. It can be an investigation into potential fraud, but also can occur where there is suspected physical abuse or other patient abuse or neglect. When you engage experienced defense counsel to represent you, intervening in the investigation to discern the investigation’s focus and scope will be one of your counsel’s first priorities.

2. The Amount of Information Already Available to the MFCU (and Federal Authorities)

Medicaid investigations often follow Medicaid audits; and, in many cases, MFCUs will target multiple entities either in succession or at the same time. As a result, by the time you learn that you are the target of a Medicaid investigation, there is a good chance that the MFCU already has a substantial amount of relevant information in its possession. This means that efforts to secure an indictment could be closer than you think, and it will be critical for your counsel to intervene and present a strong defense as soon as possible.

3. How Quickly and Effectively You Respond

Although investigators have a substantial amount of control over how long a Medicaid investigation takes, targets play a major role in determining the overall timeline as well. If you respond to requests for information promptly (provided that it is in your best interests to do so), this can help prevent the process from dragging on for longer than necessary.

4. Whether You Are Able to Keep the Investigation’s Focus and Scope Limited

While there are several reasons not to provide information to the government unnecessarily during a Medicaid investigation, one of the most important reasons is to avoid inadvertently expanding the investigation’s focus and scope. If you give the MFCU (or HHS OIG, DEA, or DOJ) reason to dig deeper, this will increase your risk while also increasing the duration of the investigative process.

5. The Government’s Findings and the Means of Resolution

The government’s findings also play a crucial role in determining the overall timeline of a Medicaid investigation. If you can clearly demonstrate full compliance with the Medicaid billing rules and regulations, you may be able to resolve your investigation relatively quickly. Conversely, if the MFCU (or HHS OIG, DEA, or DOJ) uncovers apparent evidence of Medicaid fraud, this will lead to additional inquiries that take additional time.

The means of resolution is a key factor for determining the duration of a Medicaid investigation as well. Resolving an investigation without liability (based on clear documentation of compliance) is often quickest, while settlements generally take a bit longer, and investigations that lead to grand jury subpoenas will typically be the longest of all—as the DOJ will want to ensure that it has the evidence it needs to secure an indictment.

How Healthcare Providers and Pharmacies Can Streamline the Medicaid Investigation Process While Setting the Stage for a Favorable Resolution

While some aspects of the Medicaid investigation process are beyond the target’s control, there are several steps that targeted entities and individuals can take to help streamline the process. These steps can also help set the stage for a favorable resolution. For example:

  • Respond to the Investigation Immediately – Ignoring a Medicaid investigation is never the right approach. As soon as you find out that you are a target (or may be a target), you should engage experienced defense counsel to communicate with the MFCU on your behalf. 
  • Conduct an Attorney-Client Privileged Internal Medicaid Compliance Assessment – To execute an efficient and effective defense strategy, you need to know what (if anything) the MFCU is going to find. Gathering this information involves conducting an internal Medicaid compliance assessment with your defense counsel’s oversight. 
  • Determine What Outcome to Pursue – When defending against a Medicaid investigation, it is critical to have a specific desired outcome in mind. Not only will this allow you to hone your defense, but it will also help to shorten the timeline in most cases. 
  • Focus on This Outcome While Remaining Cognizant of All Risks – As you deal with the investigation, you should focus on achieving your desired outcome while remaining cognizant of all risks. This includes not only risks you identified during your internal Medicaid compliance assessment, but also any new risks that arise during the investigative process.  
  • Work with Experienced Counsel to Seek a Favorable Pre-Charge Resolution – Working with experienced counsel is critical for minimizing your risk while simultaneously resolving your Medicaid investigation as quickly as possible. The sooner you engage counsel to represent you, the sooner your counsel can get to work on your behalf. 

Are You Facing a Medicaid Investigation? Talk to a Federal Healthcare Defense Lawyer at Oberheiden P.C. in Confidence

Our federal healthcare defense lawyers represent healthcare providers, pharmacies, and individuals in Medicaid investigations throughout the United States. If you are facing a Medicaid investigation, we encourage you to contact us promptly for more information. Call 888-680-1745 or contact us online to schedule a complimentary consultation today.

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