Federal authorities are aggressively targeting Medicare-participating health care providers in all parts of the country, including North Dakota, in False Claims Act and Anti-Kickback Statute investigations. If your business or practice is under investigation, it is important that you speak with experienced defense counsel as soon as possible.
For most Medicare-participating health care providers, federal fraud investigations come as a complete surprise. Most providers do their best to comply with the extraordinarily-complex Medicare billing regulations, and they advise their billing administrators to exercise an abundance of caution when billing Medicare for services, equipment and supplies.
Yet, Medicare fraud investigations have become commonplace in today’s health care industry. Providers in all fields of practice are subject to constant scrutiny, and the government’s reliance on automated data analysis to identify targets for federal investigations means that the unique aspects of individual practices are largely irrelevant to whether an investigation will be launched. While these unique aspects may fully explain individual providers’ billing practices, once an investigation is underway, it becomes incumbent upon the provider to demonstrate compliance and fend off federal charges.
At Oberheiden, P.C., we represent health care providers in Medicare fraud investigations throughout North Dakota and nationwide. Our attorneys have handled thousands of cases, and we provide individualized legal representation that is tailored to the unique facts and circumstances of each individual case. Whether you are a physician accused of accepting unlawful referral fees, a clinic or hospice owner accused of billing for medically-unnecessary services, or any other type of health care provider accused of any other form of Medicare fraud, we can help, and we encourage you to contact us promptly for a confidential initial consultation.
Federal Agencies that Investigate and Prosecute Health Care Providers Suspected of Medicare Fraud
Several federal agencies have jurisdiction over Medicare fraud matters. When facing an investigation in North Dakota, identifying the agency (or agencies) involved is a critical early step. This will help determine not only the most-appropriate approach to your defense, but also the scope and severity of the allegations against you, and whether the investigation is currently civil or criminal in nature.
Our attorneys have substantial experience in Medicare fraud investigations involving all relevant federal agencies. This includes experience as defense counsel for health care providers and as former federal prosecutors with the U.S. Attorney’s Office. The agencies most-commonly involved in Medicare fraud investigations include:
1. Centers for Medicare and Medicaid Services (CMS)
CMS is the federal agency responsible for administering the Medicare system, and it is one of several agencies responsible for enforcing participating providers’ statutory and regulatory obligations. CMS conducts investigations directly, and it also works with a network of “fee-for-service” audit contractors (ZPICs, MACs, and RACs) that conduct invasive audits of health care providers’ program billing practices.
2. Department of Justice (DOJ)
The DOJ is the nation’s chief law enforcement agency, and it handles both civil and criminal Medicare fraud investigations. The DOJ obtains evidence of Medicare fraud through interviews, civil investigative demands (CIDs), subpoenas, search warrants, and other means, and often works in conjunction with CMS and other agencies.
3. 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 it is specifically tasked with enforcing the federal laws that apply to Medicare participants and beneficiaries. OIG investigations can lead to civil or criminal charges, and providers targeted by the OIG can face substantial (and often business or practice-threatening) penalties.
4. Federal Bureau of Investigation (FBI)
The FBI also participates in Medicare fraud investigations trough its white-collar crimes division. With its vast investigative resources and a field office covering the state of North Dakota, it is able to efficiently and aggressively target providers statewide.
5. Drug Enforcement Administration (DEA), Internal Revenue Service (IRS) and Others
The DEA, IRS, and other federal agencies get involved in Medicare fraud investigations involving specific issues that fall within their jurisdiction. For example, the DEA routinely handles investigations involving allegations of opioid diversion and other forms of prescription drug fraud, while the IRS participates in investigations where Medicare billing issues appear related to tax evasion and other Internal Revenue Code violations.
Medicare Billing Errors that Can Trigger Civil or Criminal Prosecution
“Medicare fraud” is a broad term that encompasses civil and criminal violations of a variety of federal statutes. While most investigations involve allegations under the “false or fraudulent claims” provision of the False Claims Act, North Dakota health care providers can face prosecution under the federal health care fraud statute (18 U.S.C. § 1347), the Anti-Kickback Statute, the Stark Law, and various other laws as well. At Oberheiden, P.C. we represent health care providers in investigations involving all types of allegations under all applicable federal statutes, including:
- Billing for medical services, scans or tests that do qualify as “medically-necessary” 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.
- “Phantom billing,” or billing Medicare for services, supplies, or equipment not actually rendered, used, or purchased.
- Other billing errors such as “upcoding” (billing for services, supplies, or equipment at higher rates than the one allowed under the applicable Medicare guidelines) and “unbundling” (billing for services, supplies, and equipment at their individual rates rather than a prescribed combined, or “bundled,” rate).
- Paying or receiving “kickbacks,” referral fees, or other forms of “remuneration” in connection with referrals of Medicare-eligible patients or using Medicare-reimbursed funds.
- Improperly prescribing opioid medications to dependent patients, diverting medications, forging prescriptions, and other forms of prescription drug fraud.
Potential Consequences of Medicare Fraud Investigations in North Dakota
In Medicare fraud investigations, the potential penalties for which health care providers are at risk depend upon three primary factors: (i) whether the investigation is civil or criminal in nature, (ii) the statute (or statutes) under which prosecutors decide to pursue charges, and (iii) the volume and severity of the allegations involved. For example, the False Claims Act and the federal health care fraud statute (18 U.S.C. § 1347) impose differing penalties for similar criminal offenses, and 18 U.S.C. §1347 includes a tiered penalty structure for violations resulting in serious bodily injury or death (i.e. providing opioid medications to a dependent patient).
When deciding whether to pursue civil or criminal charges, federal prosecutors will generally focus on the element of intent, with intentional violations carrying the potential for criminal penalties. In criminal cases, prosecutors may pursue charges for mail fraud, wire fraud, money laundering, conspiracy, tax evasion, and other crimes as well, and each of these offenses carries additional severe penalties.
In general terms, the types of penalties that North Dakota health care providers can face during Medicare fraud investigations include:
Civil Penalties Under the False Claims Act, Anti-Kickback Statute, and Stark Law
- 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 Penalties Under the False Claims Act, Anti-Kickback Statute, and Federal Health Care Fraud Statute (18 U.S.C. § 1347)
- 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
For licensed medical professionals, Medicare fraud investigations can also trigger disciplinary action by their state licensing boards.
Potential Outcomes of Medicare Fraud Investigations in North Dakota
Medicare fraud investigations can potentially be resolved at any step in the process, from the earliest stages of the government’s investigation through trial, sentencing, and appeal in federal court. Potential outcomes range from termination of the investigation without charges or penalties to a criminal conviction carrying multi-million-dollar fines and decades of federal incarceration. When penalties cannot be avoided entirely, Medicare fraud investigations are often resolved through negotiations with prosecutors taking place either prior to charges being filed or during pre-trial procedures.
Depending upon the circumstances involved, a successful resolution of a Medicare fraud investigation could involve:
- 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
About Oberheiden, P.C. | A National Medicare Fraud Defense Law Firm
In order to resolve Medicare fraud investigations as quickly, discretely, and favorably as possible, health care providers must engage experienced legal counsel early in the process. Ideally, this means hiring a team of defense lawyers upon first contact from federal authorities. Our attorneys have successfully resolved numerous Medicare fraud investigations without charges being filed, and we offer all clients strategic, uncompromising legal representation that is laser-focused on the facts at hand. Meet the federal health care fraud defense team at Oberheiden, P.C.
Schedule a Free Initial Consultation
To discuss your Medicare fraud investigation with a member of Oberheiden, P.C.’s health care fraud defense team, please call 888-519-4897 or contact us online. Once you contact us, we will arrange for you to meet with a senior attorney on our defense team over the phone or in person as soon as possible.