North Carolina Health Care Fraud Defense

As a health care provider or the owner of a durable medical equipment (DME) or other medical supply company in North Carolina, facing allegations of federal health care fraud can have devastating consequences for your practice or business. In order to avoid unnecessary consequences as a result of a Medicare, Medicaid, Tricare, or Department of Labor (DOL) investigation, it is important to engage experienced defense counsel as soon as possible.

From the Atlantic Coast to Raleigh, and from Charlotte to western North Carolina’s Appalachian region, health care providers across North Carolina are being aggressively targeted in federal health care audits and investigations. With allegations ranging from honest billing mistakes to intentional Medicare and Medicaid fraud, providers targeted in these audits and investigations are at risk for a broad range of administrative, civil, and criminal penalties.

But, when facing an audit or investigation, the outcome is not a foregone conclusion. Health care providers (and other Medicare, Medicaid, Tricare, and DOL participants) can protect themselves, and they can avoid practice-threatening or business-threatening penalties. Federal health care audits and investigations are often misguided; and, even when there are billing errors that need to be corrected, the severe penalties that can flow from civil or criminal charges (including recoupments, fines, program exclusion, and federal imprisonment) can often be avoided.

Federal Health Care Fraud Defense Lawyers Serving All of North Carolina

At Oberheiden, P.C., we represent licensed practitioners, physician groups, clinics, laboratories, hospitals, hospices, home health agencies, DME companies, and other health care clients in health care audits and investigations throughout North Carolina and nationwide. Our team of federal defense lawyers includes several former health care fraud prosecutors who spent years or decades working for the U.S. Department of Justice (DOJ) prior to entering private practice. All of our attorneys have extensive experience in health care fraud matters, and we rely on this experience to aggressively execute custom-tailored defense strategies focused on protecting our clients as quickly, comprehensively, and discretely as possible.

Our experience includes representing clients in Medicare Administrative Contractor (MAC), Recovery Audit Contractor (RAC), and Zone Program Integrity Contractor (ZPIC) audits, and in investigations involving the DOJ, the U.S. Department of Health & Human Services’ Office of Inspector General (OIG), the Medicare Fraud Strike Force, and all other federal agencies and task forces. We have protected clients against substantial recoupment liability, and we have kept clients who were accused of intentional Medicare fraud out of prison. Whatever is at risk in your case, we can use our experience to protect you, and our senior attorneys will work closely with you throughout the process to keep you informed and ensure that we have all of the information we need to defend you effectively.

Frequently-Asked Questions (FAQs): Defending Against Medicare Audits and Health Care Fraud Investigations in North Carolina

Q: What are the differences between health care fraud audits and investigations?

While there are some critical differences between health care fraud audits and investigations, if you are facing an audit, it is important not to assume this means that you are safe from civil or criminal prosecution. Not only do audits often resemble investigations, but they can often lead to formal federal investigations as well. If an auditor finds evidence of a substantial volume of fraudulent billings or suspects that a provider has intentionally overbilled Medicare, it may refer the case to the DOJ or another federal agency for further action.

All of that said, one critical distinction between audits and investigations is that audits involve private contractors, not federal agencies. The MACs, RACs, and ZPICs that currently operate in North Carolina are:

  • AdvanceMed
  • CGS Administrators, LLC
  • Cotiviti LLC
  • Palmetto GBA, LLC

These are companies that work with the Centers for Medicare and Medicaid Services (CMS) on a “fee for service” basis, which means that they receive compensation based upon the volume of overbillings they uncover and recoup on the government’s behalf.

In contrast, investigations are conducted directly by federal authorities. The government agencies and task forces that are primarily responsible for investigating and prosecuting cases of suspected health care fraud include:

  • Centers for Medicare and Medicaid Services (CMS)
  • Department of Justice (DOJ)
  • Drug Enforcement Administration (DEA)
  • Federal Bureau of Investigation (FBI)
  • Office of Inspector General (OIG)
  • Medicare Fraud Strike Force
  • Opioid Fraud and Abuse Detection Unit
  • Prescription Interdiction and Litigation (PIL) Task Force

However, these are not the only agencies and task forces that get involved in federal health care fraud investigations. For example, in cases involving allegations of tax evasion or mail fraud, the Internal Revenue Service (IRS) or U.S. Postal Inspection Service (USPIS) may get involved as well.

Q: Why is my health care practice or business being targeted?

This is an important question, as determining why you are facing an audit or investigation is a critical step toward determining how to defend yourself effectively. Audits and investigations can both result from a number of different triggers. For example, ZPICs such as AdvanceMed conduct three different types of audits: (i) automated audits, (ii) semi-automated audits, and (iii) complex audits. While automated audits are usually a matter of random selection, semi-automated audits and complex audits may result from evidence of specific billing issues. Likewise, while the DEA conducts routine investigations of registered providers every three years, allegations of prescription drug fraud or diversion from patients, employees, or others may trigger a targeted investigation. The DOJ, FBI, OIG, and other agencies conduct investigations based upon “red flags” triggered by automated analysis of program billing data, and they conduct investigations based upon whistleblower claims, auditor referrals, and other targeted allegations as well.

Are you being targeted as a result of random selection? Or, have auditors or investigators already formed an opinion about your practice’s or business’s program billings? These are questions you need to answer as soon as possible.  

Q: What types of mistakes can lead to charges for federal health care fraud?

During federal health care fraud audits and investigations, auditors and prosecutors look for any evidence to suggest that the provider or business being targeted has overbilled Medicare, Medicaid, Tricare, or the DOL. This includes both intentional and unintentional billing violations, and it includes other violations that are not specific to providers’ billing practices as well. For example, some of the issues that most-commonly lead to civil and criminal charges for federal health care fraud include:

  • Inadequate or missing documentation
  • Mischaracterization of employees and independent contractors
  • Unlawful marketing and referral agreements
  • Lack of “medical necessity”
  • Financial conflicts of interest
  • Billing and coding errors
  • Telemedicine violations
  • Lack of an adequate compliance program

Q: What are the penalties for federal health care fraud?

The penalties for health care fraud vary depending upon the specific allegations involved and whether those allegations are civil and criminal in nature. While both civil and criminal violations carry the potential for recoupments, fines, other financial penalties, and program exclusion, criminal violations carry the additional risk of federal imprisonment.

Q: Could I lose my license as the result of a health care fraud audit or investigation?

Yes, potentially. Either as a result of notification provided by federal authorities or as a result of your own self-reporting obligation, your state licensing board may learn of your audit or investigation. Due to the fact that state ethics rules are often much stricter than the federal standards for civil and criminal prosecution, it is possible to face licensing action (i.e. reprimand, suspension, or revocation) even if you are not charged with a federal health care fraud offense.

Q: Do I still need to be worried if I haven’t intentionally overbilled Medicare, Medicaid, Tricare, or the DOL?

Yes, potentially. Under the False Claims Act, the Anti-Kickback Statute, the Stark Law, and various other federal health care fraud statutes, it is possible to face civil penalties even if you have not knowingly or intentionally engaged in fraudulent billing practices or an illegal compensation-based relationship. Furthermore, even if you personally are not aware of improper billings, your employees or your third-party billing administrator’s personnel may not necessarily hold themselves to the same standards to which you hold yourself.

Q: Should I hire defense counsel during an audit or investigation?

Some health care providers and company executives believe that they do not need to hire legal counsel during an audit or investigation. They believe that their personnel can handle the matter effectively, and that they do not need legal representation unless and until they get charged with a federal offense. However, waiting to hire legal representation is one of the biggest mistakes you can make. You don’t want to have to defend yourself against charges or appeal an unfavorable audit determination if you don’t have to, and it is often possible to resolve audits and investigations without charges or recoupment liability.

Q: Can Oberheiden, P.C. represent me in North Carolina?

Yes. Our attorneys are available to represent health care providers and other individuals and businesses in North Carolina in MAC, RAC, and ZPIC audits; investigations involving all federal agencies and task forces; and, grand jury and trial proceedings in North Carolina’s Eastern, Middle, and Western Districts. We are also able to represent clients in appellate matters before the U.S. Court of Appeals for the Fourth Circuit.

Schedule a Free Initial Consultation about Your Health Care Fraud Audit or Investigation

If you need to speak with a federal health care fraud defense lawyer, contact us now for a free and confidential case assessment. To speak with a member of our defense team as soon as possible, call 888-519-4897 or inquire online now.

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