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North Carolina Medicare Fraud Defense

Allegations of Medicare fraud can lead to recoupments, fines, pre-payment review, program exclusion, and other penalties. If your North Carolina health care practice or medical business is being targeted in an audit or investigation, it is important that you speak with an experienced defense lawyer as soon as possible.

Medicare funds are the lifeblood of many health care practices and medical businesses in North Carolina. However, Medicare-participating providers and companies are subject to strict federal oversight, and even unintentional billing errors can lead to devastating consequences. Audit contractors working for the Centers for Medicare and Medicaid Services (CMS) are financially-incentivized to recoup as many overpayments as possible, and agents and prosecutors employed by the Department of Justice (DOJ), the Office of Inspector General (OIG), and other agencies have devoted their entire careers to combatting Medicare fraud, waste, and abuse.

These factors make facing a Medicare fraud audit or investigation an extremely serious matter. Physicians, pharmacists, clinics, testing laboratories, hospitals, hospices, home health agencies, durable medical equipment (DME) companies, and other licensed practitioners and businesses are all at risk for being targeted, and they can all face substantial penalties. However, with a proactive and strategic defense, these penalties can be avoided, and hiring experienced defense counsel is the first step toward favorably resolving a Medicare fraud audit or investigation.

Federal Medicare Defense Lawyers Serving North Carolina

At Oberheiden, P.C., we bring centuries of experience to defending licensed health care providers and other Medicare participants in audits and investigations. We have successfully resolved thousands of audits and investigations involving Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), the DOJ, the OIG, and other federal agencies and task forces. Our practice encompasses all aspects and all phases of Medicare fraud defense, and our defense team includes several attorneys who previously served lengthy careers as health care fraud prosecutors with the DOJ.

Our highly-experienced attorneys are available to defend North Carolina health care providers, businesses, executives, board members, and other clients in audits and investigations involving:

MACs, RACs, and ZPICs Targeting North Carolina Medicare Participants

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

Federal Agencies that Investigate and Prosecute Medicare Fraud and Related Offenses

  • Centers for Medicare and Medicaid Services (CMS)
  • Department of Justice (DOJ)
  • Drug Enforcement Administration (DEA)
  • Federal Bureau of Investigation (FBI)
  • Internal Revenue Service (IRS)
  • Office of Inspector General (OIG)
  • U.S. Postal Inspection Service (USPIS)

What Do North Carolina Medicare Participants Need to Know about MAC, RAC, and ZPIC Audits?

MAC, RAC, and ZPIC audits are the frontlines of the federal government’s fight against Medicare fraud. These auditors, with have contracted with CMS as part of its “fee-for-service” audit program, are private companies that get paid to recoup Medicare overpayments on CMS’s behalf.

Unfortunately, while this is certainly a legitimate function (federal data suggest that Medicare loses hundreds of billions of dollars to overpayments every year), MAC, RAC, and ZPIC audits are not always carried out in the manner that they should be. Auditors routinely make mistakes; and, despite being contracted to uncover both overpayments and underpayments, MACs, RACs, and ZPICs routinely focus on uncovering overpayments due to the nature of the “fee-for-service” audit program.

Other key facts about MAC, RAC, and ZPIC audits include:

1. There are Different Types of MAC, RAC, and ZPIC Audits

Not only are there important differences between MAC, RAC, and ZPIC audits, but these auditors each conduct various different types of audits as well. For example, a ZPIC audit may be:

  • Automated – Automated audits typically result from random selection and involve review of billing data already in CMS’s possession.
  • SemiAutomated – Semi-automated audits can result from random selection or targeted enforcement, and they typically resolve requests for substantiating documentation.
  • Complex – Complex audits are intensive and invasive procedures in which Medicare participants are forced to affirmatively defend their program billings in order to avoid recoupments and other penalties.

2. The Consequences of These Audits Can Be Severe

Do not let the nomenclature of “audits” fool you. In many cases, MAC, RAC, and ZPIC audits can closely resemble detailed federal investigations, and the consequences can be equally severe. Not only has CMS endowed these auditors to impose recoupments, deny pending payments, review future billings prior to reimbursement, and take other “remedial” action, but MACs, RACs, and ZPICs can (and often do) refer providers to the DOJ and the OIG for civil or criminal investigation.

3. There is an Appeals Process, But it is Lengthy and Complex

While it is possible to appeal an unfavorable audit determination, the appeals process is lengthy and complex. As a result, Medicare participants should focus their efforts on preventing an unfavorable determination rather than challenging one on appeal. For example, for ZPIC audits, the appeals process involves five separate stages:

  • Request for Redetermination by a MAC
  • Request for Reconsideration by a Qualified Independent Contractor (QIC)
  • Administrative Hearing before the Office of Medicare Hearings and Appeals (OMHA)
  • Appeal to the Medicare Appeals Council
  • Review of the Medicare Appeals Council decision in federal district court

4. Audits Can Lead to Federal Investigations

As noted above, one of the greatest risks involved in facing a Medicare audit is that the audit can transition into a federal investigation. In federal Medicare fraud investigations, health care providers and businesses can face substantial penalties above and beyond those imposed as a result of the audit, including potentially criminal fines and federal imprisonment.

5. There Are Several Potential Ways to Fend Off an Unfavorable Audit Determination

The good news is that there are several potential ways to fend off an unfavorable audit determination. From challenging auditors’ methodologies to showing that they have relied on inaccurate assumptions or incomplete information, playing an active role in the audit process can greatly reduce providers’ chances of facing recoupments and other penalties. Other common mistakes made by MAC, RAC, and ZPIC auditors include:

  • Failing to provide required information
  • Failing to seek an expert opinion
  • Selectively reviewing billing data
  • Reaching inaccurate conclusions
  • Misapplying the Medicare billing regulations
  • Making procedural errors
  • Using unsound sampling and statistical methods
  • Exceeding the scope of their delegated authority

Learn more about defense strategies for MAC, RAC, and ZPIC audits:

What Do North Carolina Medicare Participants Need to Know about Federal Fraud Investigations?

When facing federal investigations, health care providers must act swiftly, and they must make informed decisions based on sound legal advice. At Oberheiden, P.C., we guide our clients through the investigative process while dealing with the authorities on their behalf, and we focus our efforts on achieving a favorable outcome as quickly, quietly, and cost-effectively as possible.

Here are five key facts about federal Medicare fraud investigations:

1. Investigations Can Target Intentional and Unintentional Billing Violations

Medicare fraud can be intentional or unintentional, and it can be committed by a provider directly or by an employee or third-party administrator on the provider’s behalf. As a result, when facing federal fraud investigations, providers cannot rely on the fact that they have not intentionally engaged in fraudulent billing practices. Attempting to defend against an investigation by acknowledging errors but claiming that they were not knowing or intentional can be a huge mistake that can expose providers to substantial civil and administrative penalties.

2. Investigations Can Target Non-Billing-Related Offenses

While billing errors are among the most-common violations targeted in Medicare fraud investigations, federal agents and prosecutors may be examining your practice or business for other statutory violations as well. This includes (but is not limited to) paying unlawful referral fees, engaging in illegal “kickback” transactions, and providing “medically unnecessary” health care services to Medicare beneficiaries.

3. Investigations Can Target Offenses Not Specific to Medicare

Federal investigations can also target offenses that are not specific to Medicare. For example, in large-scale investigations, it is not uncommon for prosecutors to attempt to collect the evidence needed to charge licensed professionals, executives, board members, and other individuals with mail fraud, wire fraud, money laundering, tax evasion, and other federal crimes.

4. Early and Aggressive Intervention is Critical to Avoiding Charges

As the target of a federal investigation, your focus should be on resolving the investigation without charges being filed. To achieve this outcome, prompt and aggressive intervention is critical. When you engage our firm to represent you, our defense lawyers will make contact with the investigating agents and prosecutors right away, and we will immediately begin gathering the information we need to execute a strategic defense.

5. Facing Charges Does Not Necessarily Mean You Will Be Convicted at Trial

In some cases, avoiding charges will be an impossibility. If you are indicted or charged with civil health care fraud, it is important not to assume that your case is over. The standard for pursuing charges is much lower than the standard for proving guilt or liability in federal district court, and our attorneys have an extensive track record of securing favorable pre-trial outcomes and verdicts at trial.

Get Started with a Free and Confidential Case Assessment

Are you being targeted in a Medicare fraud audit or investigation in North Carolina? If so, contact us to schedule a free and confidential case assessment. To speak with a member of our federal defense team as soon as possible, call 888-519-4897 or inquire online now.

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