Federal authorities, including the Medicare Fraud Strike Force, are aggressively targeting health care providers in Detroit and throughout Michigan. Oberheiden, P.C.’s federal defense attorneys are available to represent health care providers in investigations, grand jury proceedings, trials, and appeals statewide.
As a Medicare-participating health care provider, complying with the Medicare billing regulations is one of the most important aspects of your practice. Unlike billing mistakes involving private vendors and suppliers, which can usually be worked out informally, Medicare billing violations can trigger intensive federal investigations and potentially result in civil or criminal federal charges.
If you have received a target letter, civil investigative demand, subpoena, or any other form of contact from federal authorities, your business or practice is under investigation. Federal authorities are reviewing your business’s or practice’s Medicare billings; and, if you do nothing, there is a strong chance that the government’s investigation will lead to civil or criminal penalties. Mitigating this risk requires a strategic defense, and this starts with hiring experienced legal representation.
At Oberheiden, P.C., we are committed to fighting for health care providers in matters involving allegations of Medicare fraud. We handle cases involving all federal agencies and task forces at all stages of the federal law enforcement process, from investigation through trial and appeal. With a team that includes nationally-recognized defense attorneys and former health care fraud prosecutors with the U.S. Department of Justice (DOJ), we have a long record of success protecting Medicare providers against charges and prosecution.
What Do You Need to Know about the Government’s Investigation?
When faced with a Medicare fraud investigation, one of the first hurdles in building a strategic is gathering the information you need to make smart, quick decisions. With our attorneys’ centuries of combined experience on both sides of federal investigations and prosecutions, we can quickly get you up to speed on what you need to know, and we can gather any additional information necessary through promptly and forcefully intervening in the government’s investigation.
1. Which Federal Agencies and Task Forces are Handling the Investigation?
Identifying the agencies and task forces that are handling your investigation is necessary to executing a pre-indictment defense strategy, and it will also generally provide insight into a number of key aspects of the government’s inquiry. Under which statute (or statutes) are you being targeted? Is the investigation civil or criminal in nature? How fast will the investigation move? What are your chances of negotiating a resolution without charges being filed? These are all critical questions that identifying the agencies involved in your investigation will help answer.
The agencies and task forces that typically handle Medicare fraud investigations include:
- Centers for Medicare and Medicaid Services (CMS) – CMS administers Medicare at the federal level, and it routinely investigates participating providers whose billing practices suggest potential fraud.
- Department of Justice (DOJ) – As the nation’s top law enforcement agency, the DOJ investigates and prosecutes health care providers suspected of improperly billing and collecting payment from Medicare.
- Department of Health and Human Services Office of Inspector General (OIG) – The OIG is the law enforcement division of the Department of Health and Human Services (DHHS), and its primary role is to help protect Medicare and the other federal health care benefit programs from fraud.
- Federal Bureau of Investigation (FBI) – The FBI’s white-collar crimes division also has jurisdiction over federal Medicare fraud matters.
- Medicare Fraud Strike Force – The Medicare Fraud Strike Force is a joint task force of the DOJ, OIG, and other agencies, and it has a full-time operation stationed in Detroit, Michigan.
2. Why am I Being Accused of Medicare Fraud?
For many health care providers, discovering that they are being targeted in a Medicare fraud investigation comes as a total surprise. They diligently maintain comprehensive Medicare billing compliance programs, and they have no interest in billing the government for amounts that are not owed.
When it comes to targeting health care providers for suspected Medicare fraud, federal authorities are not picky. They will go after any health care provider whose Medicare billings appear to suggest fraudulent practices. In fact, with most investigations triggered by automated review of aggregated program billing data, in most cases the decision to investigate has nothing to do with a Medicare participant’s identity or the specific nature of its business or practice.
In most cases, during Medicare fraud investigations federal agents will be looking for evidence of the following types of fraudulent billing practices:
- “Upcoding,” or the practice of billing for services, supplies, and equipment at higher rates than the one allowed.
- “Unbundling,” or the practice of billing for services, supplies, and equipment at their individual rates rather than a prescribed combined rate.
- “Phantom billing,” or billing for services, supplies, or equipment not actually rendered, used, or purchased.
- Billing for services or tests that do not qualify as “medically necessary” under the Medicare program billing guidelines.
- “Double-billing” for services, supplies, or equipment by billing Medicare and/or another government benefit program or private insurer.
- Offering or accepting “kickbacks” or other forms of improper payment made using Medicare-reimbursed funds.
3. What are the Risks of Being Targeted in a Medicare Fraud Investigation?
In terms of statutory penalties, the risks of being targeted in a Medicare fraud investigation depend on whether the investigation is civil or criminal in nature. Both civil and criminal cases carry the potential for financial penalties and loss of Medicare eligibility, while criminal cases also carry the potential for federal imprisonment. For licensed health care providers (physicians, pharmacists, and others), the risks also include the potential for state board licensing action; and, since the standards for ethics violations are different from those for federal prosecution, it is possible to face license suspension or revocation even if an investigation does not lead to formal charges.
The risks of being targeted in a Medicare fraud investigation also depend on the specific allegations against you as well as the scope of those allegations. The financial penalties for Medicare fraud are applied on a “per claim” basis, with each separate Medicare billing constituting a separate “claim.” As a result, while some cases are fairly small in context, it is not unusual for providers to face hundreds of thousands or even millions of dollars in liability.
The civil and criminal penalties for Medicare fraud under the False Claims Act, the Anti-Kickback Statute, the federal health care fraud statute (18 U.S.C. § 1347) and other federal laws include:
Civil Medicare Fraud Penalties
- Recoupment of overbilled amounts
- Denial of pending claims
- Pre-payment review of future claims
- Civil fines
- Treble (triple) damages
- Attorneys’ fees
- Exclusion from Medicare participation
Criminal Medicare Fraud Penalties
- Criminal fines
- Federal imprisonment (including the potential for life imprisonment in cases where fraudulent Medicare practices result in a patient’s death)
- Exclusion from Medicare participation and other program-related penalties
4. What are the Potential Outcomes of a Medicare Fraud Investigation?
The potential outcomes of a Medicare fraud investigation range from early termination of the investigation without liability to criminal prosecution and sentencing after a guilty verdict at trial. At Oberheiden, P.C., we rely upon our defense attorneys’ vast federal experience to develop and execute case strategies that are designed to protect our clients to the greatest extent possible in light of the particular facts and circumstances at hand. However, while we have resolved many of our clients’ cases without any civil or criminal liability, and while none of our clients have lost their ability to practice as a result of an investigation in which we have been involved, we cannot guarantee any particular outcome under any circumstances.
In order of priority, the outcomes we pursue for health care providers targeted in Medicare fraud investigations include:
- Avoiding civil or criminal charges
- Obtaining dismissal of charges prior to trial
- Negotiating civil penalties with no criminal plea
- Reducing felony charges to misdemeanors
- Avoiding federal imprisonment
What Do You Need to Know about Oberheiden, P.C.?
If your Michigan health care business or medical practice is under investigation by the DOJ, CMS, FBI, OIG, Medicare Fraud Strike Force, or any other federal authority, you need to make an informed decision about your legal representation. Here are five reasons why health care providers in Michigan and nationwide trust Oberheiden, P.C.’s federal health care fraud defense team:
- Significant Experience in Medicare Fraud Cases – We have successfully represented Medicare providers all over the country in investigations and prosecutions involving the DOJ, CMS, FBI, OIG, Medicare Fraud Strike Force, and other federal authorities.
- Strategic, Proactive, and Results–Oriented Defense – We work closely with our clients to develop and execute custom-tailored defense strategies that are designed to result in discrete and cost-effective favorable outcomes.
- Accessible and Client-Focused Attorneys – Throughout your case, you will work directly with our senior attorneys. You will have direct access 24/7, and we will make sure you feel confident about the direction of your case at all times.
Start with a Free and Confidential Case Assessment
To speak with a member of our federal health care fraud defense team about your Medicare fraud investigation in Michigan, please call 888-519-4897 or contact us online. We will arrange for you to speak with an attorney as soon as possible.