Nashville Health Care Fraud
Skilled Nashville Health Care Fraud Defense Lawyers
Recently, several high-profile cases of Medicare fraud in Tennessee have increased the government’s focus on health care providers in the Nashville area. If your business or practice is being targeted in a federal investigation, it is critical to make sure you understand the risks involved. Contact a our experienced Nashville health care fraud defense lawyers to discuss your case.
Since Vanderbilt University Medical Center agreed to pay $6.5 million to settle alleged Medicare billing violations to a hidden camera sting operation targeting psychological counselors at a local nursing home, Tennessee has been the site of several high-profile health care fraud investigations in recent years. As federal investigators learn more about the local area and certain federal health care benefit program billing practices that appear to be common among Nashville health care providers, they are increasingly targeting local providers for fines, recoupments, program exclusion, and other penalties.
If your Nashville-area health care business or medical practice is being targeted in a federal investigation, it is imperative that you understand the risks involved. Penalties under the False Claims Act (FCA) and other statutes are applied on a per-claim basis; and with fines upwards of $21,000 per individual violation, providers accused of submitting “false and fraudulent” claims in violation of the FCA can easily face insurmountable financial liability. When you add in recoupments, treble damages (three times the government’s actual losses), and the potential for licensing action as well as loss of Medicare, Medicaid, and Tricare eligibility – providers have little choice but to take the approach that their livelihoods could be on the line.
Of course, this all assumes that the government’s investigation is civil in nature. In criminal investigations that apply to health care providers that bill federal benefit programs, the penalties can easily include multi-million-dollar fines and years – and in the worst cases decades – of federal incarceration. While most investigations targeting legitimate health care providers are civil in nature, if prosecutors believe they have evidence of intent, they can pursue criminal charges.
Nationally-Recognized Health Care Fraud Defense Team Representing Providers in Nashville, TN
At Oberheiden, P.C., our Nashville health care fraud defense lawyers concentrate our practice on defending providers and other entities in federal health care fraud investigations. With a national reach practice, we are increasingly receiving calls from providers in Nashville and other cities throughout Tennessee. While this is due in part to the U.S. Department of Justice’s (DOJ) decision to place a team from its Opioid Fraud and Abuse Detection Unit in the state in 2017, we routinely hear from providers facing allegations ranging from prescription drug fraud to acceptance of unlawful referral fees.
Our health care fraud defense team is comprised of highly-skilled senior attorneys, many of whom served distinguished careers with the DOJ prior to entering private practice. With our team approach, each client receives the full benefit of our attorneys’ collective and complementary experience. When you engage our firm to represent you, the Nashville health care fraud defense attorneys representing you against the government will include:
- Dr. Nick Oberheiden – Founder and Managing Partner of Oberheiden, P.C., Dr. Nick Oberheiden is a well experienced federal law health care fraud defense attorney. He has successfully represented providers across the country in investigations, civil and criminal prosecutions, and appeals.
- Lynette S. Byrd – Ms. Byrd is a Partner with Oberheiden, P.C. and a former Assistant United States Attorney. During her tenure as a federal prosecutor, Ms. Byrd handled numerous high-profile cases involving allegations under the False Claims Act, Anti-Kickback Statute, and other health care fraud laws.
Meet the other attorneys on our health care fraud defense team.
“We have never dealt with legal counsel who is so down to earth and compassionate toward his clients. [Dr. Nick Oberheiden] has a level of compassion and dedication that one would only expect from a family member. He is responsive and has even worked with us on weekends . . . . In a situation where we felt like there was little hope, [Dr. Oberheiden] provided a bright light at the end of a dark tunnel. There is no one better and if you are seeking a Federal Criminal Attorney, you can’t go wrong with this gentleman. He has a heart for what he does that we don’t often see in today’s legal profession.” – Health Care Provider, Firm Client
“[Oberheiden, P.C.] is unlike your stereotypical law firm. Their level of professionalism, dedication, and sensitivity to me and my situation made me feel comfortable and confident I was in the right hands. Hopefully I won’t find myself in a situation where I’d need law services again but if I did they would be the first I’d call.” – Health Care Provider, Firm Client
Decades of Experience in All Health Care Fraud Matters
With our extensive background in federal health care fraud investigations involving all major law enforcement agencies and task forces, we are significantly positioned to represent individuals and businesses facing challenging circumstances and uncertain futures. Regardless of the circumstances involved in your investigation, our Nashville health care fraud defense lawyers can use our past experience inside of the government’s health care fraud enforcement regime to develop and execute a strategy that is specifically-tailored to resolving your investigation as quickly and favorably as possible.
Our attorneys have decades of experience on both sides of federal health care fraud investigations involving issues including, but not limited to:
- Double-Billing – Double-billing for services, supplies, and equipment is among the most-common allegations in health care fraud investigations focused on providers’ program billing practices. This includes billing the same program (such as Medicare, Medicaid, or Tricare) multiple times for the same service, billing multiple programs for the same service or item, or billing the same service or item to a federal benefit program and a private insurer.
- Billing for Medically-Unnecessary Services – Federal funds are available only for reimbursement of services, supplies, and equipment that are considered medically-necessary under the applicable program billing regulations. Billing past length-of-stay limitations and in violation of other restrictions related to medical necessity are highly likely to trigger federal investigations.
- Billing for Services Not Provided (“Phantom Billing”) – Billing for services, supplies, and equipment not actually provided is among the most-common allegations in federal health care fraud investigations as well. While some providers engage in so-called “phantom billing” intentionally, many of these cases involve administrative mistakes and other honest errors.
- Billing for Non-Allowable Costs – Certain costs, such as operational expenses, are not eligible for reimbursement under Medicare, Medicaid, or Tricare. Attempting to bill for these costs can trigger investigations into other aspects of providers’ billing practices as well.
- Billing for Unlicensed or Excluded Services – Program regulations prohibit providers from billing for services provided by unlicensed practitioners. Billing for services provided by excluded providers (including excluded third-party providers) is prohibited as well.
- Non-Compliance with Conditions – In addition to billing in accordance with the substantive limitations on reimbursement eligibility, health care providers must also comply with the procedural conditions for Medicare, Medicaid, and Tricare reimbursement. In today’s environment, even technical violations can trigger exhaustive investigations into providers’ program billing practices.
- Unbundling – Program billing regulations require certain services and items to be billed at “bundled” rates. Unbundling (whether intentionally or unintentionally) is another practice that is often the catalyst for invasive and comprehensive health care fraud investigations.
- Up-Coding – Similar to unbundling, up-coding involves billing for a service or item at a higher reimbursement rate than the one that is supposed to be used. Also similar to unbundling, up-coding can trigger investigations that can lead to civil or criminal charges.
- Use of Incorrect Billing Code – Using the incorrect billing code can be an unintentional form of upcoding. Providers must have adequate compliance controls in place to avoid submitting incorrect billing codes and garnering the attention of federal authorities.
- Kickbacks, Bribes, and Referral Fees – The Anti-Kickback Statute prohibits most forms of compensation (or “remuneration”) in connection with purchases, leases, and patient referrals involving funds from federal health care benefit programs. Unless a transaction qualifies for a statutory or regulatory safe harbor, providers on both sides of the transaction can face civil and criminal penalties.
- Physician “Self-Referrals” – The Stark Law prohibits transactions involving federally-reimbursed funds between physicians and entities or individuals with which they have financial relationships. It applies to non-exempted transactions related to “designated health services,” which include clinical laboratory services, imaging, hospital services, outpatient prescriptions, physical therapy, and radiology, among others.
- Falsifying Patient Records – Falsifying patient records is another practice which, whether committed intentionally or unintentionally, is likely to trigger a federal inquiry. This includes backdating records, falsely reporting test results, fabricating office visits, and various other forms of fraud.
- Prescription Drug Diversion – With the DOJ’s heightened scrutiny of health care providers’ opioid prescription practices, investigations targeting alleged opioid diversion have become increasingly common. Common allegations include selling prescriptions, dispensing opioids without valid prescriptions, and dispensing prescription medications without medical necessity.
- Drug Shorting and Refill Schemes – Drug shorting and refill schemes are commonly used to divert prescription medications as well. They are also common triggers for federal prescription drug fraud investigations.
- Compound Pharmacy Fraud – With the recent resurgence in compound pharmacy practice, the number of investigations targeting compound pharmacies has increased as well. Allegations against compound pharmacies run the gamut from accepting kickbacks to billing for individual ingredients that are not medically necessary.
- Other Forms of Prescription Drug Fraud – Other common allegations against physicians, pharmacists, clinics, and other providers whose practices involve prescription medications include forging prescriptions, dispensing more medication than was prescribed, illegally importing medications and ingredients, prescribing or administering medications without medical necessity, and prescribing medications without conducting in-person exams.
- Physician Certification Fraud – Physician certifications are a central component of program-reimbursed home health and hospice care practice. Providing fraudulent certifications, forging certifications, backdating recertifications, and other forms of fraud can expose certifying physicians, home health agencies, and hospices to both civil and criminal penalties.
- Election Statement Fraud – Election statement fraud is a common allegation in federal investigations targeting hospices as well. This includes treating patients without obtaining valid election statements, failing to maintain adequate patient records, forging and backdating election statements, and various other forms of fraud.
Nashville Health Care Fraud Defense Lawyers: Answers to FAQs
Q: Which federal authorities are typically involved in health care fraud investigations?
Numerous federal authorities pursue investigations against health care providers in the Nashville area. This includes federal health care and law enforcement agencies, as well as special task forces that have been formed for the specific purpose of pursuing recoupments and penalties for federal health care benefit program fraud. Our Nashville health care fraud defense lawyers routinely represent clients in matters involving the:
- Centers for Medicare and Medicaid Services (CMS)
- Department of Defense (DOD)
- Department of Health and Human Services (DHHS) Office of Inspector General (OIG)
- Department of Justice (DOJ)
- Department of Labor (DOL)
- Drug Enforcement Administration (DEA)
- Federal Bureau of Investigation (FBI)
- Medicare Fraud Strike Force
- Opioid Fraud and Abuse Detection Unit
- U.S. Attorney’s Office
Q: What types of referral fee arrangements are permissible under the Anti-Kickback Statute and the Stark Law?
Despite the broad prohibitions under the Anti-Kickback Statute and Stark Law, numerous forms of compensation-based arrangements are still permissible. For example, statutory and regulatory safe harbors exist for transactions involving:
- Arrangements with hospitals
- Bona fide employment relationships
- Compensation of non-physician practitioners
- Cooperative health service organizations
- Electronic health record and prescription services
- Fair-market-value compensation
- Group purchasing organizations
- Indirect compensation arrangements
- In-office ancillary services
- Incidental benefits and non-monetary compensation
- Investment interests
- Isolated transactions
If you have been accused of offering or accepting an illegal kickback, bribe, or referral fee, our Nashville health care fraud defense attorneys can examine the transaction to determine whether a safe harbor or defense is applicable to protect you from liability.
Q: What are the civil and criminal penalties for health care fraud?
The civil and criminal penalties for health care fraud vary by statute. For example, under the False Claims act, civil penalties include fines of approximately $21,000 per fraudulent claim, recoupments, treble damages, and program exclusion. In criminal cases, providers can face fines of $250,000 for individuals (or $500,000 for businesses) and up to five years of federal imprisonment. The Anti-Kickback Statute imposes similar civil penalties plus up to $50,000 in civil monetary penalties (CMP) per violation, and criminal defendants can face five-figure fines and long-term imprisonment.
In criminal cases, providers will often face prosecution under a variety of other federal laws as well. Charges for conspiracy, controlled substance offenses, mail fraud, wire fraud, money laundering, and other crimes can easily result in multi-million-dollar exposure and the potential for, under the worst facts, decades of federal incarceration.
Why Choose Oberheiden, P.C. in Nashville, TN?
1. Prosecutorial Experience
Our health care fraud defense team includes several attorneys who were senior health care fraud prosecutors with the U.S. Department of Justice. Our Nashville health care fraud defense lawyers have had success on both sides of federal health care fraud investigations, and in some cases, we helped craft strategies still in use at the DOJ.
2. Proven Results
We have resolved an overwhelming percent of our clients’ cases without federal indictments, and to date we have resolved 100 percent of False Claims Act investigations without civil or criminal liability. To date, not a single client of our firm has been forced to cease operations due to an investigation in which we have been involved.
3. Exclusive Focus
Our practice is devoted to health care fraud defense. We are constantly focused on defending clients in federal health care fraud investigations, and we take pride in finding new and innovative ways to defend our clients against the government’s evolving tactics.
4. Team-Oriented Representation
We do not assign cases to individual attorneys. Each member of our firm will contribute his or her experience to helping you avoid civil and criminal responsibility.
5. 24/7 Accessibility
We are available when and where you need us. We understand that your patients are your top priority, and we can work with you to minimize the impact of your investigation on your business or practice as much as possible.
Get Started with a Free and Confidential Case Assessment
For more information about our health care fraud defense practice, please contact us to schedule a free and confidential case assessment. You can reach us 24/7 at 888-680-1745, or send us your contact information and our Nashville health care fraud defense lawyers will be in touch as soon as possible.