Under the False Claims Act and other federal statutes, Oklahoma health care providers can face severe civil and criminal penalties in Medicare fraud investigations. At Oberheiden, P.C., our attorneys bring centuries of combined legal experience to defending providers against business and practice-threatening allegations.
For health care providers in Oklahoma, Medicare fraud investigations can lead to severe consequences. In civil investigations, providers can face recoupments, fines, program exclusion, and other penalties. In criminal cases, prison time is on the table. To avoid these consequences, health care providers must defend themselves effectively, and they must know how to avoid mistakes that could actually enhance their risk of federal prosecution.
At Oberheiden, P.C., our attorneys have centuries of combined experience in Medicare fraud matters. Our attorneys are nationally-renowned defense lawyers, former federal prosecutors, and trusted advocates and advisors for health care providers nationwide. We have successfully defended Medicare fraud investigations nationwide with the result of no civil or criminal charges being filed; and, in cases where our clients have been charged, we have secured results including obtaining dismissal of charges prior to trial.
Experienced Defense Counsel for Medicare Fraud Investigations Involving All Federal Agencies in Oklahoma
Multiple federal agencies conduct Medicare fraud investigations. When facing an investigation, identifying the agency (or agencies) involved can help determine:
- What triggered the investigation?
- What are the specific allegations underlying the investigation?
- Is the investigation civil or criminal in nature?
- What are the chances of securing a favorable pre-trial resolution?
Surprisingly, answering these questions is not nearly as easy as it sounds. During Medicare fraud investigations, agents and prosecutors play their cards close to the vest; and, while they seek to collect voluminous amounts of records from health care providers, the amount of information they share is extremely limited. As a result, gaining insight into an investigation requires the ability to assess the investigation from the government’s point of view, and this is where having defense attorneys who are former federal prosecutors comes into play.
When you engage our firm to represent you, our senior federal defense attorneys will promptly intervene in the government’s investigation to identify the agencies involved and begin gathering the information needed to answer the questions listed above. Most Medicare fraud investigations involve one or more of the following:
- Centers for Medicare and Medicaid Services (CMS)
- Department of Justice (DOJ)
- Drug Enforcement Administration (DEA)
- Department of Health and Human Services Office of Inspector General (OIG)
- Federal Bureau of Investigation (FBI)
- Internal Revenue Service (IRS)
What are Some of the Most-Common Allegations Against Medicare-Participating Health Care Providers?
The majority of Medicare fraud investigations target alleged billing and coding violations. Under the False Claims Act and the federal health care fraud statute (18 U.S.C. §1347), health care providers can face civil and criminal penalties for improperly billing Medicare. Under the Anti-Kickback Statute and the Stark Law, providers can also face penalties for offering, soliciting, paying, and accepting unlawful payments in relation to referrals for Medicare-reimbursed services.
In our experience, some of the most-common allegations in CMS, DEA, DOJ, FBI, IRS, and OIG investigations include:
- Billing for services not actually rendered to patients
- Billing for services that do not qualify as “medically necessary” under the Medicare billing guidelines
- Billing for services at a higher rate than the one allowed (referred to as “upcoding”)
- Billing for related services and supplies at individual rates (referred to as “unbundling”)
- Inflating charges, falsifying patient records, and making unnecessary use of durable medical equipment (DME)
- Double-billing Medicare and another government benefit program (such as Medicaid or Tricare) or a private insurer
- Improperly prescribing, distributing, or billing for prescription medications
- Paying illegal referral fees, rebates, or kickbacks out of Medicare-reimbursed funds
- Failing to properly report and pay taxes on Medicare overpayments
What are the Potential Penalties in Medicare Fraud Investigations?
In Medicare fraud investigations, the potential penalties are determined first by whether the government is pursuing charge that are civil or criminal in nature. In civil cases, the penalties are exclusively financial and program-related (i.e. prepayment review or Medicare exclusion). In criminal cases, in addition to these types of penalties, health care providers can face federal imprisonment.
The next factor in determining a health care provider’s potential exposure is the specific statute (or statutes) under which federal prosecutors file charges. For example, while the False Claims Act, Anti-Kickback Statute, and Stark Law all provide for similar civil penalties, the criminal penalties under the False Claims Act and the federal health care fraud statute (18 U.S.C. §1347) are very different. In criminal cases, federal prosecutors will often pursue charges for mail fraud, wire fraud, money laundering, and other related crimes as well, and each of these offenses carries additional fines and an additional term of imprisonment.
The third significant factor in determining a health care provider’s risk is the volume of the government’s allegations. In each of the statutes listed above, the penalties apply on a per-claim or per-violation basis. This means that health care providers being targeted for tens or hundreds of improper reimbursement requests will face much less exposure than a provider who is facing review of thousands of Medicare billings.
With these considerations in mind, the types of penalties for which health care providers can be at risk in Medicare fraud investigations 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
For physicians, pharmacists, and other licensed health care providers, Medicare fraud investigations carry the potential for state licensing board disciplinary action as well. Since state ethics standards vary from the standards for civil or criminal culpability under federal law, it is possible for a Medicare fraud investigation to lead to license suspension or revocation even if it does not result in charges being filed.
What are the Potential Outcomes of Medicare Fraud Investigations?
While these are the potential penalties, there is also the potential to resolve a Medicare fraud investigation without any civil or criminal liability. While the potential outcomes of each individual case are greatly depending upon the particular facts and circumstances involved, our attorneys have successfully handled numerous investigations with the result of no civil or criminal liability for our client. Depending upon the facts and circumstances involved, a successful result could mean any of the following:
- 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
How Can Oberheiden, P.C.’s Health Care Fraud Defense Team Protect Me?
When we represent health care providers in Oklahoma and other states, we utilize a variety of different defenses that we custom-tailor to the details and unique aspects of each individual client’s case. Our attorneys call upon their vast experience in Medicare fraud matters to identify and assess potential defenses and then build a cohesive defense strategy designed to secure a favorable result as quickly as possible. Some of the ways we defend health care providers include:
1. Aggressively Intervening in the Government’s Investigation
By promptly and aggressively intervening in the government’s investigation, we can gather the information we need to determine which individual defenses are available; and, if charges appear to be imminent, we can seek to slow down the process in order to pursue a pre-charge resolution.
2. Challenging the Government’s Evidence
Regardless of the facts at hand, the burden of proof is always on the government. If federal prosecutors cannot prove their case – either because their evidence is lacking or because their evidence is inadmissible in court – then you do not deserve to be charged.
3. Asserting Safe Harbors and Other Defenses
In many Medicare fraud cases, statutory safe harbors and other defenses will insulate health care providers from liability. Our attorneys are well-versed in these defenses and have a proven track record of using them to our clients’ advantage.
4. Relentlessly Defending Our Client at All Stages of Prosecution
While some law firms take a wait-and-see approach to Medicare fraud litigation, our experience has shown that relentlessly pursuing an aggressive and proactive defense strategy typically works to our clients’ advantage.
What Should I be Doing if I have Been Contacted by Federal Authorities?
If your Oklahoma health care business or medical practice is under investigation for Medicare fraud, what should you be doing? At Oberheiden, P.C., we recommend:
- Make note of any deadlines in subpoenas, civil investigative demands or other formal requests for information.
- Take appropriate measures to prevent the destruction or deletion of potentially-relevant files.
- Do not allow federal agents to speak with your personnel unless otherwise advised by legal counsel.
- Vigilantly protect your privilege against self-incrimination, and know when you are – and aren’t – required to comply with investigators’ demands.
- Seek experienced legal representation immediately.
Schedule a Free Case Assessment at Oberheiden, P.C.
To speak with a member of our federal health care fraud defense team about your Medicare fraud investigation in Oklahoma, call 888-519-4897 or contact us online now. You can reach us 24/7, and we will schedule your free and confidential initial case assessment as soon as possible.