Possible Statutory Violations for Medicare Billing Fraud Involving Amniotic Fluid Injections
Fraudulent Billing for Amniotic Injections
“Fraudulent billing” is a broad term referring to a healthcare provider’s fraudulent requests for reimbursement that are submitted to Medicare, Medicaid, or any other government health care benefit program. Allegations for fraudulent billings can be investigated and prosecuted as civil or criminal offenses under various statutes such as the False Claims Act or the Anti-Kickback Statute.
Federal agencies are increasingly scrutinizing healthcare providers for amniotic fluid injection billing fraud and billing for medically unnecessary injections. Amniotic fluid injections are amniotic stems cells that a provider prescribes to patients to treat a variety of ailments involving damaged tissue cells. These shots are injected near the tissue cells that are damaged and work to help these cells recover and regenerate faster.
Providers can engage in fraudulent billings of these injections in many ways such as the following: (1) billing amniotic injections as if they were other services that are covered by Medicare or (2) making false statements that the amniotic injection was prescribed to treat a wound or injury when they were instead given for pain management purposes. Treatments for “pain management” raise a red flag to federal agencies because they are often medically unnecessary and open the door for federal investigations and violations of the False Claims Act.
Applicable Statutes Governing Medicare Billing
Fraudulent billing for amniotic injections can violate numerous federal statutes and provisions. It is important to be aware of these statutes so that you are able to work towards full compliance. If you are aware of instances of noncompliance either through an internal audit, federal investigation, whistleblower tip, or other means, it is time to retain an experienced healthcare defense attorney. Below we highlight the most common statues in this area:
- False Claims Act (“FCA”): This is the most important statute when dealing with allegations of false billings to Medicare for amniotic fluid injections. The FCA prohibits improperly billing Medicare for services and products that are non-reimbursable and has both civil and criminal penalties. Providers are prohibited from submitted false or fraudulent claims for reimbursement to Medicare. Examples of violations include: (1) submitting claims for products/services that are excluded from eligibility; (2) submitting claims for products/services that do not satisfy the medical necessity standard required by Medicare; (3) submitting claims for one product/service that was eligible when another product/service was instead provided that was not eligible.
- Federal Health Care Fraud Statute (18 U.S.C. Section 1347): This statute prohibits attempts to defraud any health care benefit program or to fraudulently obtain any money or property under the control of any health care benefit program.
- ***Under the FCA and the federal Health Care Fraud Statute, there needs to be evidence of intent or knowledge to substantiate criminal charges. However, under the FCA, providers can also face civil penalties for negligent billing errors and other inadvertent mistakes regarding Medicare and other healthcare benefit program rules and regulations.
- The Eliminating Kickbacks in Recovery Act (“EKRA”): EKRA prohibits labs, clinics, recovery centers, and clinical treatment facilities from accepting or paying kickbacks for illegal patient referrals.
- The Anti-Kickback Statute (“AKS”): AKS prohibits knowing and willful payments that are made to induce patient referrals or generate business activity involving any service payable to government healthcare programs.
- ***The AKS is limited to federal and state healthcare programs, while EKRA includes both state and federal healthcare programs (e.g., Medicare and Medicaid) and private health insurance plans.
- Stark Law: This law prohibits physicians from providing patient referrals to other healthcare entities where those physicians or a member of their immediate family have a financial interest, relationship, or other financial benefit.
- U.S. Code Section 1001: This section prohibits individuals including healthcare providers from making false statements to the government such as by submitting statements to the government that are false.
Overall, the primary concerns for federal agencies are whether the healthcare provider is accepting illegal payments from their suppliers for amniotic injections and whether the provider is then falsely billing Medicare for reimbursement.
Some of the above provisions may have applicable safe harbors and exemptions. An attorney can help the provider determine whether they have a strong defense under one of the safe harbors or exemptions that can be used to fight certain healthcare fraud allegations.
Why Clients Choose Us to Defend Them Against Billing Fraud
Fraudulent billings for amniotic fluid injections are a real concern for providers, as federal agencies are closely scrutinizing providers’ billing records and compliance policies for possible false billings and violations of the False Claims Act. It is critical to a provider’s defense that competent and experienced counsel be retained immediately. Below are top reasons why clients choose Oberheiden, P.C. to defend them against false billing and healthcare fraud allegations:
- Decades of experience in both government and private practice: Our team has experience working in the government as former FBI agents and prosecutors as well as experience working for private litigants. This interdisciplinary approach gives us the inside knowledge of government and private operations to anticipate the government’s next steps and how to best respond to any situation. We have extensive experience representing providers in billing fraud investigations and prosecutions and carrying out aggressive defense strategies to reduce liability exposure with the core aim of eliminating civil or criminal liability.
- Specific notable experience in the healthcare industry: When retaining an attorney to help you fight billing fraud allegations involving amniotic injections, it is very important to make sure that your firm’s attorneys have prior experience in the healthcare sector. Several of our firm’s attorneys are former state and federal healthcare fraud prosecutors and therefore possess an intricate knowledge about Medicare and other governmental program billing regulations along with relevant healthcare statutes. We can provide you with detailed and thorough healthcare fraud defense services and compliance assistance.
- Highly successful track record of defending clients and eliminating liability: You should always research an attorney’s track record in cases similar to yours—healthcare fraud defense and Medicare billing regulations. This includes past results as well as a reliable track record in federal defense and healthcare investigations initiated by federal agencies. Our attorneys have an extensive track record representing clients in federal investigations and experience defending our clients from the investigative stages to the trial stages.
- Dedication and commitment to fully defending our clients: Clients can tell when their attorneys are fully committed to defending them. Our prior clients have repeatedly shown their appreciation for our attorneys’ dedication, perseverance, and enthusiastic attitude with respect to handling their cases. Having an attorney on your side that truly cares about representing you can sometimes be the key to successfully defending you.
- Continuous availability to assist our clients: Our attorneys are always available to answer our clients’ questions and concerns, including on evenings and weekends. We make it a point to provide our clients with continuous updates about the status of pending motions, investigations, government negotiations, and any other matter relevant to our clients’ cases. Our 24/7 availability is a critical factor of importance for our clients who are comforted by the fact that they can always contact us to resolve any issue or answer any question.
Dr. Nick Oberheiden, founder of Oberheiden P.C., focuses his litigation practice on white-collar criminal defense, government investigations, SEC & FCPA enforcement, and commercial litigation.