Medicare fraud allegations can have serious ramifications even for health care providers that are not formally charged. If your Nevada medical practice or health care business is under investigation, our federal defense attorneys can help protect you against unnecessary consequences.
A variety of federal agencies investigate health care providers under a broad range of circumstances. If you or any other member of your business or practice has been contacted by federal authorities, discerning the details of the government’s investigation is the first step toward asserting an effective defense.
At Oberheiden, P.C., our attorneys have extensive experience representing clients in Medicare fraud investigations. We have successfully resolved investigations involving all relevant federal agencies, and we have protected health care providers against civil and criminal charges in the face of serious and wide-ranging fraud allegations. When you engage our firm to represent you, our attorneys will work quickly to gather the evidence needed to build a comprehensive and strategic defense, and we will use our experience to pursue a favorable resolution as quickly, discretely, and cost-effectively as possible.
What Nevada Health Care Providers Need to Know about Medicare Fraud
1. What is “Medicare fraud”?
In order to properly orient yourself during a Medicare fraud investigation, it is first necessary to have a clear understanding of the federal definition of “Medicare fraud.” Contrary to popular belief, it is not necessary to intentionally overbill the government in order to face Medicare fraud allegations. Under the False Claims Act and other federal statutes, both intentional and unintentional billing violations can trigger Medicare fraud liability, with the question of intent determining whether prosecutors will pursue charges that are civil or criminal in nature.
Intentional and unintentional billing violations that can trigger allegations of Medicare fraud include:
- Billing for medical services, scans or tests that do meet the criteria for “medical necessity” under the Medicare program billing guidelines.
- “Double-billing” Medicare and/or another government benefit program (such as Medicaid or Tricare) or private insurer for services, supplies, or equipment.
- Paying or receiving “kickbacks,” referral fees, or other forms of improper payment in connection with referrals of Medicare-eligible patients or using Medicare-reimbursed funds.
- “Phantom billing,” or billing Medicare for services, supplies, or equipment not actually rendered, used, or purchased.
- “Upcoding,” or billing for services, supplies, or equipment at higher rates than the one allowed under the applicable Medicare guidelines.
- “Unbundling,” or billing for services, supplies, and equipment at their individual rates rather than a prescribed combined, or “bundled,” rate.
2. Which federal agencies investigate and prosecute health care providers suspected of Medicare fraud?
Various federal agencies investigate and prosecute health care providers suspected of Medicare fraud. In most cases, a Medicare fraud investigation in Nevada will involve one or more of the following authorities:
- Centers for Medicare and Medicaid Services (CMS) – CMS maintains an aggressive enforcement program and routinely investigates Medicare-participating providers for all types of alleged billing and coding errors.
- Department of Justice (DOJ) – The DOJ investigates and prosecutes providers for alleged civil and criminal Medicare fraud offenses as well as other related federal crimes.
- Department of Health and Human Services Office of Inspector General (OIG) – The OIG is responsible for enforcing health care providers’ responsibilities under the Medicare billing program guidelines through civil and criminal investigations and prosecutions.
- Federal Bureau of Investigation (FBI) – The FBI often gets involved in cases involving billing fraud and other Medicare-related fraudulent offenses.
- Internal Revenue Service (IRS), Drug Enforcement Administration (DEA), and Others – Depending upon the specific allegations involved, the IRS, DEA, and various other federal agencies may participate in Medicare fraud investigations as well.
3. How do CMS, the DOJ, and other agencies decide which health care providers to investigate?
In most cases, the decision to investigate a particular health care provider is made based upon automated review of aggregated Medicare billing data. CMS, the DOJ, the OIG, and other agencies constantly monitor program billings using automated data analytics software; and, when this software identifies an “anomaly” in a particular provider’s billings – whether an unusually large number of billings for a particular service or an overall volume of billings that is abnormal for the provider’s geographic area – this can trigger an active investigation. Investigations can also be triggered by CMS “fee-for-service” contractor (ZPIC, MAC, and RAC) audits, as well as patient complaints and whistleblower claims.
4. What are the penalties for Medicare fraud?
Understanding the penalties for Medicare fraud first requires an understanding of the differences between civil and criminal Medicare fraud prosecution. Most Medicare fraud investigations are civil, meaning that the government is not alleging that the provider acted with intent. If there is evidence to suggest that a provider has intentionally overbilled Medicare, then federal prosecutors may pursue criminal charges under the False Claims Act, the federal health care fraud statute (18 U.S.C. § 1347), or any of the other various statutes that apply.
- A cardiologist in Nevada was indicted for his role in a scheme to defraud Medicare. According to the indictment, the cardiologist is alleged to have prescribed numerous fraudulent opioid prescriptions to patients for no legitimate medical purpose. The indictment further alleges that the cardiologist performed EKGs on patients and then falsified the outcomes of these EKGs in order to convince patients that they had coronary issues and needed to receive cardiac treatment. The fraudulent prescriptions and the medical treatments based on the falsified EKG reports was then submitted to Medicare for reimbursement. The cardiologist is charged with 36 counts of distribution of controlled substances and 3 counts of healthcare fraud.
- A hospice facility in Nevada has agreed to a monetary settlement with the United States to resolve allegations that it engaged in healthcare fraud. According to the settlement, the hospice facility allegedly was submitting false claims to Medicare for its patients. The hospice facility allegedly knew its patients did not qualify for hospice care as they were not terminally ill. The hospice facility still performed services on these patients as if they were terminally ill and then submitted the bills for said services to Medicare for reimbursement. The hospice facility in Nevada is one of many facilities owned by its parent company that is alleged to have engaged in various acts of healthcare fraud. The parent company will pay $53 million back to Medicare to settle the allegations arising from its Nevada facility and other facilities located throughout the United States.
- A doctor and two nurse practitioners in Nevada were all indicted for their respective roles in a scheme to defraud Medicare. According to the indictment, the doctor and nurses engaged in a scheme to distribute prescriptions for opioids in exchange for cash payments. The doctor allegedly would give the nurses pre-signed prescriptions for hydrocodone and oxycodone and the nurses would sell the prescriptions to patients in exchange for cash. The cost of the fraudulent prescriptions was then billed to Medicare for reimbursement. As a result of the scheme by the doctor and the nurses, Medicare paid out $3.7 million.
- Two women were sentenced in District of Nevada for their roles in a scheme to defraud the Nevada Medicaid program. According to plea agreement prior to sentencing, the women started a business that was to provide therapy related services for children that were Medicaid eligible. The women recruited eligible children to their business but did not perform the therapy services on the children. The women, however, did bill Medicaid as if they had performed the services. The women falsified care plans for the children and then billed Medicaid approximately $8,000 a month as if the care plans had been properly implemented. As a result of this scheme, the two women received $1 million from Medicaid for the services they did not perform.
In a typical case, the potential penalties that will be on the table in a Medicare fraud investigation 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
These are the potential penalties under the four primary statutes that focus specifically on federal health care benefit program fraud: the False Claims Act, the federal health care fraud statute (18 U.S.C. § 1347), the Anti-Kickback Statute, and the Stark Law. In criminal cases, federal prosecutors may also pursue charges for offenses such as mail fraud, wire fraud, money laundering, and tax evasion, and each of these offenses carries additional fines and prison time. Additionally, if federal prosecutors cannot prove fraud but they can prove an attempt or conspiracy, then the government can still file charges that have the potential to result in substantial fines and long-term imprisonment.
Another factor to consider for licensed health care providers (such as physicians and pharmacists, among others), is the risk of state licensing board disciplinary action. A federal Medicare fraud investigation can trigger disciplinary action; and, since the standards for culpability differ between federal fraud statutes and state ethics rules, licensed providers can face discipline even in cases where an investigation is terminated without charges being filed.
5. What are the potential outcomes of a Medicare fraud investigation?
When facing Medicare fraud investigations, health care providers must do everything possible to minimize the consequences of the government’s inquiry. This means engaging experienced legal counsel, and playing an active role in the development and execution of a strategic defense. Potential outcomes range from termination of the investigation without charges to a criminal conviction on multiple counts; and, regardless of the facts at hand and your attorneys’ track record, no outcome is ever guaranteed.
In Medicare fraud investigations, we typically focus on securing the following results, in order of priority:
- 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
Experienced, Insightful, and Strategic Defense for Medicare Fraud Investigations in Nevada
If you are facing a Medicare fraud investigation in Nevada, it is important that you retain experienced legal counsel as soon as possible. At Oberheiden, P.C., we provide insightful and experienced representation based upon our attorneys’ centuries of combined experience in federal health care fraud matters. We are passionate advocates who believe in protecting the health care providers who serve a critical role in our society, and our goal is to ensure that none of our clients face unwarranted consequences as a result of federal agents looking into their Medicare billing practices.
When you choose the federal health care fraud defense team at Oberheiden, P.C.:
- We will promptly intervene in the government’s investigation and begin working immediately to protect you against federal charges.
- We will utilize our experience to identify and pursue all pertinent defenses, including challenging the sufficiency of the government’s evidence, asserting statutory safe harbors, and seeking to have inadmissible evidence excluded from trial.
- We will provide you with direct contact information for all members of your defense team, which will be comprised exclusively of senior health care fraud defense attorneys.
- We will work closely with you to understand what happened, why it happened, and what can be done to remedy any issues, and we will ensure that you feel confident and informed at every stage of our representation.
- Most importantly, we will not stop fighting for you until we have exhausted all options to secure the favorable outcome that you deserve.
Speak with a Medicare Fraud Defense Lawyer in Confidence
Is your Nevada health care business or medical practice under investigation for Medicare fraud? If so, we encourage you to contact us promptly for a free and confidential initial consultation. To speak with a member of our defense team as soon as possible, call 888-519-4897 or tell us how to reach you online now.