Memphis Health Care Fraud Defense
Proven Memphis Health Care Fraud Defense Lawyers
For Memphis health care providers, the risk of being targeted in a federal investigation is a very real concern. Allegations of billing fraud, offering and accepting kickbacks, and other statutory violations can lead to civil or criminal charges, and avoiding substantial penalties requires a strategic and proactive defense. Contact our Memphis health care fraud defense lawyers to discuss your situation as soon as possible.
“Health care fraud” is a broad term that encompasses a broad range of federal offenses. Primarily involving the improper acquisition of funds from Medicare, Medicaid, and Tricare, health care fraud can take a variety of different forms, and providers in Memphis are increasingly being targeted for alleged offenses ranging from offering and accepting kickbacks to falsifying patient records.
Even if you are confident in your business’s Medicare, Medicaid, and Tricare compliance programs, any inquiry from federal agents needs to be taken extremely seriously. Federal investigations can quickly expand in scope; and under laws such as the False Claims Act, Anti-Kickback Statute, and Stark Law, even unintentional violations can result in significant financial liability. Federal investigations can trigger licensing action and other consequences as well. Therefore, providers facing federal investigations must execute comprehensive defense strategies focused on the realities of their present circumstances.
Strategic and Aggressive Memphis Health Care Fraud Defense Lawyers Representing Providers
Our firm’s experience allows us to obtain favorable results in a significant percentage of the complex and high-stakes federal health care fraud investigations that we handle for our clients. Focusing our practice in the area of health care fraud defense, we offer practical advice and strategic representation for providers facing investigations from all federal law enforcement agencies and task forces. Whether you have received a civil investigative demand (CID), grand jury subpoena, or letter from the U.S. Attorney’s Office, we can advise you of the best path forward, and our Memphis Health Care Fraud Defense Lawyers can represent you in all communications with federal authorities while steering the investigation toward a favorable resolution.
At Oberheiden, P.C., we offer:
- Well over 100 years of combined experience in federal health care fraud investigations.
- Government side knowledge and insights from attorneys who spent decades as health care fraud prosecutors with the U.S. Department of Justice prior to entering private practice.
- Significant results for health care providers, including to date resolving 100 percent of False Claims Act investigations with no civil or criminal liability.
- A team-oriented approach which means that each of our senior health care fraud defense attorneys will be involved in helping you avoid civil liability or criminal charges.
- Client-centric legal representation that includes prompt responses, custom-tailored legal strategies, and 24/7 access to the attorneys on your defense team.
What Our Clients Say
While we are more than happy to discuss our experience in health care fraud investigations and litigation, we also like to let our clients speak for themselves. Here are just two examples of testimonials from health care providers who have chosen the health care fraud defense team at Oberheiden, P.C.:
“Dr. Oberheiden has successfully represented our company in various federal health matters. . . . Dr. Oberheiden quickly understands all issues and is able to convincingly present the client’s side of the story. From my experience with other lawyers, I consider Dr. Oberheiden to be among the best attorneys we have ever used. Should we ever need legal help, the first thing our company will do is to call Dr. Oberheiden.” – Health Care Provider, Firm Client
“Our experience with [Oberheiden, P.C.] was overwhelmingly positive! We recently brought a range of complex legal issues to the table, which they responded to with a systematic, prudent approach. Throughout our work together, Oberheiden, P.C. served as an invaluable source of practical guidance and legal leadership. We would recommend them highly and without reservation. . . .” – Health Care Provider, Firm Client
20 Common Allegations in Federal Health Care Fraud Investigations
While there are unique aspects to all federal investigations, most investigations targeting health care providers focus on certain specific types of allegations. Each of our defense team attorneys has extensive experience representing providers accused of a wide variety of violations. Our Memphis health care fraud defense lawyers are knowledgeable and proven in representing those accused of health care fraud.
Double-billing can include:
- submitting multiple reimbursement requests for the same service or item to Medicaid, Medicare, Tricare, or another health care benefit program,
- submitting duplicate reimbursement requests to multiple programs, or
- submitting duplicate reimbursement requests to a program and a private insurer.
2. Billing for Medically-Unnecessary Services
Medicare, Medicaid, Tricare, and other benefit program funds are available only for services and items that the government has deemed medically necessary. Inpatient treatment lasting beyond the program-approved length of stay, use of more-expensive treatment options when less-expensive services are available, and providing necessary medications for non-necessary procedures are just a few examples of services that would be considered medically-unnecessary under federal program billing guidelines.
3. Billing for Services Not Provided (“Phantom Billing”)
Billing for services, supplies, and equipment not actually provided to patients is referred to as “phantom billing,” and has the potential to lead to both civil and criminal penalties. Although some cases of phantom billing are intentional, many investigations target billings that are the result of administrative mistakes and other human errors.
4. Billing for Non-Allowable Costs
Some costs are eligible for program reimbursement, and some aren’t. Billing for non-allowable costs (such as operational expenses) is considered a form of health care fraud.
5. Billing for Unlicensed Services
Billing for services provided by unlicensed individuals is considered a form of health care fraud as well. This includes services provided by unlicensed therapists and counselors, physicians who have lost their medical licenses, and other unlicensed practitioners.
6. Billing for Excluded Service Providers
If a provider has been excluded from Medicare, Medicaid, Tricare, or another health care benefit program, billing for that provider’s services is considered to be a fraudulent practice.
7. Non-Compliance with Conditions
In addition to only billing for qualifying services and items, providers must also submit all bills in compliance with the applicable program terms and conditions. Non-compliance with conditions is grounds for denial of payment and recoupment of previously-paid amounts.
Unbundling refers to billing services and items at their stand-alone rates when the applicable program regulations call for a reduced, “bundled” reimbursement rate. As with other billing and coding violations, both intentional and unintentional unbundling can trigger federal inquiries and expose providers to financial penalties.
Up-coding refers to billing one service as another in order to obtain the other service’s higher reimbursement rate. Up-coding is another form of billing and coding fraud that can lead to False Claims Act liability.
10. Use of Incorrect Billing Code
Any other mistakes resulting in submission of an incorrect billing code can trigger False Claims Act liability as well. In the vast majority of cases, federal health care fraud investigations target inadvertent billing mistakes that are the result of administrative errors not deserving of criminal culpability.
11. Kickbacks, Bribes, and Referral Fees
The Anti-Kickback Statute generally prohibits payment of referral fees (referred to as “kickbacks” and “bribes” under the statute) out of federally-reimbursed funds. However, there are numerous safe harbors available, and many types of referral fee arrangements are exempted from federal prosecution.
12. Physician “Self-Referrals”
The Stark Law is similar to the Anti-Kickback Statute in that it prohibits various types of compensation arrangements involving federally-reimbursed funds. However, its scope is much more limited. The Stark Law prohibits certain payments in connection with referrals for “designated health services” involving physicians and their related entities. Similar to the Anti-Kickback Statute, various safe harbors and exceptions apply.
13. Fabricating Test Results or Providing Improper Treatment
Fabricating test results is another common allegation in health care fraud investigations that can reflect both intentional and unintentional billing violations. In addition, often due to shortcomings in providers’ recordkeeping practices, investigators will routinely allege that providers’ program billings do not reflect appropriate treatment or prescription options in light of test results reported.
14. Falsifying Patient Records
In addition to alleging that providers have fabricated test results, federal agents will often accuse providers of falsifying other patient records as well. This can include billing for treatments or prescriptions not provided, overreporting the duration of treatment sessions, and recording improper diagnoses in order to bill for unnecessary services or services not provided.
15. Prescription Drug Diversion
Diversion refers to the practice of providing prescription medications to individuals other than the patients to whom they have been (or should be) prescribed. Physicians, pharmacists, clinics, home health agencies, hospices, and other providers are all routinely targeted in investigations involving allegations of prescription drug diversion.
16. Drug Shorting and Refill Schemes
Drug shorting and refill schemes are common allegations in prescription drug fraud investigations as well. In many cases, these investigations focus on individual licensed professionals and staff members who may be diverting medications for sale or personal use.
17. Compound Pharmacy Fraud
Investigations targeting compound pharmacies can focus on issues ranging from unlawful kickback and referral fee arrangements – to issues involving specific ingredients in compound medications. These issues are often highly-technical in nature, and we have particular experience fending off federal inquiries on behalf of compound pharmacies.
18. Other Forms of Prescription Drug Fraud
Along with prescription drug diversion, drug shorting and refill schemes, and compound pharmacy fraud, providers are increasingly being targeted for other prescription-related offenses as well. This includes offenses such as:
- Dispensing more medication than prescribed
- Falsifying and forging prescriptions
- Illegally importing prescription medications
- Inaccurately reporting test results in order to issue prescriptions
- Prescribing medications without conducting in-person exams
19. Physician Certification Fraud
Home health agencies and hospices are subject to certain program billing restrictions that go above and beyond those that apply to other types of providers. This includes the requirement to obtain physician certifications (and recertifications) for all program beneficiaries. Failure to obtain valid physician certifications, forging certifications, and other fraudulent practices are common allegations in investigations targeting home health agencies and hospices in Memphis.
20. Election Statement Fraud
In addition to obtaining valid physician certifications, hospices must also obtain valid election statements from all program beneficiaries. Failure to notify patients of their rights (and the rights they waive by signing election statements), falsification of election statements, and various other forms of fraud can trigger liability under the False Claims Act and other federal health care fraud statutes.
FAQs: What You Need to Know if You Are Facing a Federal Health Care Fraud Investigation
Q: What steps should I take after being contacted by federal authorities?
If you have been contacted by federal authorities with regard to your business’s health care benefit program billings, your first step should be to speak with a Memphis health care fraud defense attorney. You need to make sure you avoid critical mistakes, and you need to gain a clear understanding of the allegations against you as soon as possible. When we represent health care providers in federal matters, our preliminary steps typically include:
- Making contact with the authorities involved to intervene in the investigation
- Determining whether the investigation is civil or criminal in nature
- Conducting an internal assessment to identify any potential grounds for civil or criminal charges
- Preserving records relevant to the government’s investigation
- Advising physicians, billing administrators, and other key personnel on how to respond to inquiries from federal agents
- Developing a strategic plan to timely respond to any subpoenas, civil investigative demands (CIDs), or other formal requests for information
Q: Is it possible to resolve my investigation without facing charges?
Yes, absolutely. When we represent health care providers during the investigative process, this is our primary objective. In the majority of the cases we have handled, we have been successful in resolving our clients’ investigations not only without charges, but without any civil or criminal liability.
Q: What are the potential consequences of being prosecuted for health care fraud in Memphis?
In civil health care fraud investigations, the potential penalties include fines, recoupments, treble damages (three times the government’s actual losses), program exclusion, and various other forms of financial liability. In criminal cases, the fines are typically much higher (up to $500,000 for organizations), and individuals can also face long-term federal imprisonment (a single violation of the False Claims Act carries a prison sentence of five years). These penalties are applied on a per-violation basis, which means that providers accused of submitting multiple “false and fraudulent” claims can face inordinate financial liability.
In addition to statutory penalties, providers can face license suspension or revocation, loss of hospital privileges, and various other practical consequences as well.
Q: Do I need to hire legal representation for my federal health care fraud investigation?
Yes, without a doubt. The federal government’s top health care fraud investigators and prosecutors are good at what they do – and they take their jobs very seriously. If you are being targeted for prosecution, you may be charged unless you mount a successful defense during the government’s investigation. At Oberheiden, P.C., our Memphis health care fraud defense lawyers have a notable record of success, and we can help protect you against the government.
Q: What should I do if I am aware of deficiencies in my business's Medicare, Medicaid, or Tricare billing compliance program?
If you are aware that your business has overbilled the government, you may have an obligation to report the issue to the appropriate authorities. However, self-reporting billing violations could also expose you to further investigation and additional financial liability. Before you self-report (or voluntarily disclose any other information to federal agents or prosecutors), it is imperative that you seek legal advice from an experienced health care fraud defense attorney.
Additional Resources for Memphis, TN Health Care Providers
Anti-Kickback Statute Investigations
- Anti-Kickback Statute Exceptions
- Medical Research Studies and Anti-Kickback Investigations
- Mistakes to Avoid in Anti-Kickback Investigations
- What You Should Do When You Are Under Investigation for Anti-Kickback Violations?
Compound Pharmacy Fraud Investigations
- Avoiding Criminal Charges in Tricare Compound Pharmacy Investigations
- Compound Pharmacy Investigations: Questions You Should Ask Your Attorney
- Defending Compound Pharmacies in Tricare Fraud Investigations
- What Is Compound Pharmacy Fraud?
False Claims Act Investigations
- 5 Things You Need to Know About the Federal False Claims Act
- Avoiding Criminal Charges in False Claims Act Cases
- False Claims Act & Qui Tam Defense
- What You Should Do When You Are Under a False Claims Act Investigation
Home Health Agency and Hospice Fraud Investigations
- What Home Health Agencies Should Do to Avoid a Government Investigation
- Home Health Fraud – Common Characteristics
- How to Defend Against Hospice Fraud Allegations
- The Federal Government Is Finding New, Aggressive Ways to Combat Home Health Fraud
Stark Law Investigations
- Important Differences between the Anti-Kickback Statute and Stark Law
- What Are the Compensation Arrangement Exceptions to the Stark Law?
- What Are the Ownership and Investment Interest Exceptions to the Stark Law?
- What Is the Personal Service Exception Under the Stark Law?
Request a Confidential Initial Consultation at Oberheiden, P.C.
If you need a health care fraud defense lawyer in Memphis, we encourage you to contact us promptly for a free initial case assessment. The attorneys on our health care fraud defense team are standing by, and we are available to speak with potential clients 24/7. To request an appointment at Oberheiden, P.C., with our Memphis health care fraud defense lawyers please call (888) 519-4897 or inquire online now.