Santa Ana Federal Health Care Fraud Defense
Experienced Health Care Fraud Defense Attorneys in Santa Ana, California
Medical professionals and health care businesses that fall under the cloud of a federal investigation, audit, or prosecution could find their liberty, financial security, and professional license in jeopardy. With the national media and government law enforcement authorities at the local, state, and national levels focused on the opioid overdose epidemic and health care program fraud, health care professionals have never faced a higher risk of being caught in an investigation or prosecution by a government entity.
This increased scrutiny includes President Trump declaring the opioid crisis a “health emergency” and Attorney General Jeff Sessions announcing the creation of the Opioid Fraud and Abuse Detection Unit. Government entities at all levels of government also have been initiating actions for recoupment of alleged public expenditures stemming from the improper prescription of opioids. These public entities have sought of reimbursement of tens of billions of dollars for public expenditures related to the opioid crisis. Federal law enforcement authorities and local government entities have been pursuing so-called “pills mills” that improperly prescribe opioids as part of the heightened efforts to pursue civil and criminal actions against parties who engage in health care fraud schemes.
Physicians, pharmacists, and other health care professionals in Santa Ana and throughout Orange County, California have increasingly been ensnared in investigations by federal law enforcement agencies like the Department of Justice (DOJ) and the Drug Enforcement Agency (DEA). False billings of Medicare and other state and federal health insurance programs have become an increasing focus of regulators in the shadows of the opioid epidemic.
Why Oberheiden, P.C. Has an Excellent Reputation for Health Care Fraud Defense in Santa Ana and Throughout Orange County
Targets of federal investigations, audits or criminal indictments that retain Oberheiden, P.C. take solace in the fact that they are represented by a competent law firm comprised of former federal prosecutors. Our litigation experience and thorough understanding of Department of Justice health care investigation policies and prosecutions have provided an insider’s advantage that physicians, drug rehabilitation centers, compound pharmacies, urgent care facilities, medical labs, and other health care businesses and professionals seek out when facing civil or criminal liability.
Our skilled Southern Californian federal criminal defense attorneys have established our national reputation for preventing investigations and audits conducted by federal authorities from proceeding to indictments. If you are already facing a federal indictment, our clients understand the value of representation from a team of lawyers who collectively have handled over 500 jury trials and thousands of grand jury proceedings. Some of the reasons health care providers seek us out include:
- Trusted and featured by the media in Southern California
- Protection of our clients’ professional licenses
- Avoided criminal indictment of clients in vast majority of federal investigations
- Never had a client held civilly or criminally liable in a False Claims Act action
- Successful dismissal of a federal indictment (extremely uncommon because 16 grand jurors must unanimously agree to indict for a federal crime)
- More than 70 years of collective DOJ experience
- Former DOJ prosecutors who have handled thousands of criminal prosecutions
- Effective and persuasive representation of thousands of federal grand jury proceedings
- Effective representation in over a thousand grand jury investigations
These are just a few of the many reasons that our law firm has received acclaim as an industry leader in defense of health care professionals and companies facing draconian penalties in federal court.
Recent Health Care Prosecutions in Orange County
Santa Ana health care professionals and others throughout Orange County have been swept up in the crackdown on doctors, pharmacies, and other licensed medical professionals related to prescription pain drugs. Over 115 medical professionals were arrested for health care fraud earlier this year. The allegations were similar to many health care fraud prosecutions in California as they targeted alleged fake drug rehabilitation and treatment facilities and services. Department of Justice officials declared the case to be the largest health care fraud enforcement action, involving over 400 arrestees based on allegations of false billings. The focus on the opioid epidemic is reflected in the fact that 120 of those arrested were charged with offenses related to the unlawful prescription and distribution of opioids and other narcotics. The fraudulent schemes involved but were not limited to the following:
- Submitting fraudulent claims and receiving payments from Medicare and private health insurers based on prescription medications that were not filled by pharmacies
- Health care fraud and drug diversion schemes involving kickbacks
Three Orange County physicians that were arrested in the crackdown were charged with the following:
- Santa Ana and Newport Beach physicians were charged with health care fraud for billing TRICARE, the military health care program. The scheme allegedly involved prescribing drugs to patients that never received a medical exam. One of the physicians paid the other doctor $200 for each prescription. The physician that paid this fee reportedly received $1.2 million for referring prescriptions to a local pharmacy that submitted billings to TRICARE for over $4.8 million.
- Another Orange County doctor who practices in Laguna Beach was indicated by a federal grand jury on 34 counts of unlawfully prescribing controlled substances and a count of making a false representation on a DEA registration application. The physician was allegedly accused of selling prescriptions to drug dealers and addicts for fees as high as $3,000 without a medical justification.
This massive criminal sweep is just one example of the abundant law enforcement resources being devoted to pursuing health care fraud. The federal agencies that pursue these investigations and prosecutions include the following:
- Drug Enforcement Agency (DEA)
- Internal Revenue Service Criminal Investigations
- Department of Defense (DOD)
- Department of Justice (DOJ)
- United States Postal Service, Office of the Inspector General (USPS-OIG)
- Department of Labor – Employee Benefits Security Administration (DOL-EBSA)
- Department of Health and Human Services-Office of Inspector General (DHH-OIG)
Statutes Used by Federal Prosecutors to Impose Civil & Criminal Liability in Health Care Fraud Cases
Our Orange County federal health care fraud attorneys at Oberheiden, P.C. have successfully defended clients facing the full range of statutes used by federal authorities to target health care professionals. Some of the statutes used by federal prosecutors include the Criminal Health Care Fraud Statute (18 U.S.C. 1347), the Anti-Kickback Statute (42 U.S.C. 1320a-7b), the Stark Law (42 U.S.C. 1395nn), and the False Claims Act (31 U.S.C. 3729-3733).
Criminal Health Care Fraud Statute: An individual can be liable under this statute for any intentional scheme to defraud a health care benefit program or making false statements to obtain funds from such a program. The punishment for a violation is harsh, including a maximum of up to ten years imprisonment and a fine of up to $500,000 or double the amount of the fraud.
Stark Law. This law forbids a doctor from referring Medicare patients to providers of certain designated medical services with which the physician has a “financial relationship.” While this statute might seem straightforward, the terms “financial relationship” and “referral” are somewhat ambiguous, which means that well-meaning health care providers often inadvertently run afoul of this law. The term “financial relationship” is construed broadly to include any direct or indirect investment or ownership interests held by the referring doctor. If you are convicted of a Stark violation, the consequences include mandatory reimbursement of the referral fee received, $15,000 for each service based on an unlawful referral, plus three times the amount of the fee, and potential exclusion from future participation in the Medicare program.
Our seasoned Santa Ana federal health care fraud lawyers are thoroughly versed in the defenses and exceptions under the Stark statute. While statutory exceptions might provide a valid defense, the Stark Law is a strict liability offense, which means a prosecutor can obtain a conviction even if the violation was inadvertent or accidental. If the government proves the commission of the offense was intentional, the penalties also might include exclusion from participation in Medicare and other federal health programs and benefits. Some of the exceptions our law firm might use include:
- Referrals for ancillary in-office radiology and laboratory services
- Non-monetary compensation under $300 in value that is not solicited or calculated based on the value or volume of referrals
- Commercially reasonable transactions where a written arrangement for compensation exists that specifies a timeframe for the services
- Indirect compensation where the benefit received represents fair market value unrelated to any referrals if the arrangement is written and signed by the parties
Anti-Kickback Statute. The Anti-Kickback Statute (AKS) forbids giving or offering anything of value to induce referrals for Medicare business. This federal statute exposes violators to criminal liability, including five years imprisonment and a fine up to $25,000. Conviction under the AKS also carries a punishment of exclusion from Medicare programs for a minimum of five years. Our law firm of former federal prosecutors has successfully defended clients accused of illegal kickback arrangements with effective defense strategies like establishing the applicability of “safe harbor” provisions.
False Claims Act (FCA). The FCA is the civil law weapon most frequently used by the U.S. Department of Justice (DOJ) to pursue cases of health care fraud. The statute forbids presenting or causing to be presented a fraudulent or false claim to receive payment from the federal government. The law also prohibits knowingly making a fraudulent or false statement material to obtaining payment for the false claim. A variety of schemes fall under the auspices of the law, such as billing for services not performed, “unbundling,” and “upcoding.” A determination of civil liability can result in monetary penalties and treble damages. Actions under the FCA often are initiated by private citizens in whistleblower lawsuits. While the DOJ will be given an opportunity to intervene, the person who started the lawsuit (called the “relator”) can receive massive financial rewards.
How Serious Is the Risk of Prosecution for Health Care Fraud?
While it might be tempting to presume that individuals and companies in the medical industry rarely face signficiant liability of health care fraud, the statistics tell another story.
- The DOJ recovered $19.3 billion in civil settlements and judgments from parties accused of health care fraud between 2009 and 2016.
- During a recent one-year period, the Medicare Fraud Strike Force, which is comprised of the FBI, individual U.S. Attorney’s Offices, the DOJ, and HHS’s Office of Inspector General, initiated criminal proceedings against 353 people.
- The average term of imprisonment for people convicted of health care fraud charges brought by the Medicare Fraud Strike Force was four years.
Excelling at Health Care Audit & Investigation Defense
If you are a health care provider, you know that you could easily become the target of a routine audit by Medicare, a private insurer, or a state licensing agencies. We have extensive experience handling all forms of health care audits, including those conducted by Zone Program Integrity Contractors, Recovery Audit Contractors, and other enforcement agencies.
Oberheiden, P.C. assists health care providers with compliance practices designed to reduce the risk of our clients being selected for an audit and to minimize mistakes that might be revealed by an audit. Overpayment to health care providers frequently is the result of inadvertent coding or billing errors rather than an intention to perpetrate fraud. Health care professionals and businesses can significantly reduce their risk of liability by creating a billing compliance plan to mitigate the potential for errors. Certain types of billing procedures increase the risk of an audit, so our Santa Ana health care audit defense attorneys advise clients to adopt a compliance plan to mitigate this risk.
Our law firm has consistently guided our clients facing a federal health care audit through the process without the government electing to pursue claims of civil or criminal liability. When you undertake the task of preparation for a compliance audit, we can guide you through the process of reviewing regulations, staff compliance training, and verification of your documentation. Our Santa Ana health care audit defense attorneys will work with you to ensure critical deadlines are met and required records are accessible. We also provide a roadmap of the process and advise our clients on how to respond and interact with the auditors.
Health Care Fraud Criminal Defense in Santa Ana, Orange County
Criminal Medicare fraud prosecutors must prove beyond a reasonable doubt that the accused willfully or knowingly presented a false claim, or participated in health care fraud or kickbacks. However, a conviction does not require actual knowledge of the false claim. Rather, reckless disregard of the truth or deliberate ignorance is sufficient to expose medical professionals and companies to criminal sanctions. Many recent prosecutions focus on doctors and practices that provide services or drugs that are not medically necessary. Our clients take comfort in our knowledge and experience associated with handling 500 federal jury trials and thousands of federal grand jury proceedings. This background means we understand clinical practice guidelines, DRG’s, conditions of payment, CPT’s, and applicable standards of care when defending our clients.
Put Our Former Federal Prosecutors to Work for You; Contact Santa Ana’s Health Care Fraud Defense Lawyers Today
Our Santa Ana, CA health care fraud defense attorneys tenaciously protect the professional practices and reputations of our clients. To speak with a member of our team of lawyers, we invite you to call us at (888) 519-4897 or request a free case evaluation online now.
Compliance – Litigation – Defense