Seattle Health Care Fraud Defense
Health care fraud investigations involving the U.S. Department of Justice (DOJ), Centers for Medicare and Medicaid Services (CMS), and other agencies can lead to financial penalties, program exclusion, and even federal imprisonment. Our firm brings over 100 years of experience to defending Seattle health care providers against the government. Contact our Seattle health care fraud defense lawyers to discuss your situation.
For health care providers in Seattle, the dangers of federal health care fraud allegations are very real. Allegations of overbilling Medicare, Medicaid, Tricare, and other government benefit programs can lead to civil or criminal prosecution; and if convicted, providers can face insurmountable financial penalties and the potential for years, if not decades, behind bars. Investigators and prosecutors assigned to task forces such as the Medicare Fraud Strike Force have a mandate to aggressively pursue charges against providers suspected of fraud, waste, and abuse. Providers targeted in federal investigations must act swiftly to protect themselves against charges, conviction, and sentencing.
Just how big are the risks? In a civil case only involving charges under the False Claims Act (most cases will involve multiple charges under a variety of federal statutes), providers can face recoupments, treble (triple) damages, fines of approximately $21,000 per false claim, and loss of federal health care benefit program eligibility. In a criminal case, the fines can reach $250,000 for individuals (or $500,000 for businesses), and prosecutors can seek up to five years of federal imprisonment for each individual offense.
If your health care business or medical practice is being targeted in a federal fraud investigation in Seattle, you absolutely must present a strategic defense. If the investigative process continues unchecked, prosecutors will keep working until they find sufficient evidence to file charges, and they will prosecute you to the fullest extent of the law. While few health care providers expect to garner the federal government’s attention, and fewer still actually believe they have done something wrong – the reality is that the breadth of our nation’s health care laws creates significant exposure even for providers who accidentally commit billing violations. Do you need a law firm that can provide a strategic defense? Contact the proven Seattle health care fraud defense lawyers at Oberheiden, P.C.
Strategic Defense for Seattle Health Care Providers Accused of Fraud
At Oberheiden, P.C., we focus our practice on representing clients in health care fraud investigations and prosecutions. We have a legal team that includes former senior DOJ prosecutors, that have decades of experience in the “other side” thinks – this is so because they have worked for the other side. We have a client list that includes licensed practitioners, health care business owners and executives, physician-owned entities, hospitals and other medical facilities, pharmacies, hospices, and home health agencies, and durable medical equipment (DME) companies, among others. We offer seasoned experience and significant insights into successfully defending our clients against health care fraud allegations. From audits and investigations to criminal trials and appeals, we do it all – and we have a notable record of success at each stage of the process.
During your case, you will work closely with the attorneys on our health care fraud defense team. With our team approach, each of our attorneys plays a role in every case we handle, ensuring that each client receives the very best legal representation that we have to offer. The attorneys on our health care fraud defense team include:
- Dr. Nick Oberheiden – Dr. Oberheiden is our firm’s founder and Managing Partner. He represents health care practitioners across the nation utilizing his extensive and in-depth knowledge of the Medicare billing regulations and health care fraud defense strategies.
- Lynette S. Byrd – Ms. Byrd is a former Assistant United States Attorney who has significant knowledge of the government’s investigative process in health care fraud matters. She offers a wealth of practical knowledge for providers facing civil and criminal investigations.
- Glenn A. Harrison – Mr. Harrison is a former Special Assistant United States Attorney who spent close to a quarter century working for the DOJ. He has extensive knowledge in the areas of health care fraud and related federal offenses.
- Heath Hyde – Mr. Hyde is a proven trial attorney who has personally handled more than 400 trials and approximately 1,000 grand jury investigations. He has over 20 years of experience on both sides of complex felony cases.
Meet the rest of your attorneysat Oberheiden, P.C..
“Our companies have worked with firms all over the country within various specialties and now use [Oberheiden, P.C.] almost exclusively. Nick represented our companies in some federal law investigations. His guidance and expertise allowed us to continue to concentrate on our core business as he dealt with the complex legal issues.” – Health Care Provider, Firm Client
“Dr. Oberheiden has successfully represented our company in various federal health matters involving the OIG, the Department of Labor, and the Department of Health and Human Services. Dr. Oberheiden quickly understands all issues and is able to convincingly present the client’s side of the story. From my experience with other lawyers, should we ever need legal help, the first thing our company will do is to call Dr. Oberheiden.” – Health Care Provider, Firm Client
Skilled Seattle Health Care Fraud Defense Lawyers for All Health Care Fraud Matters
We rely upon our extensive experience to effectively represent individuals and corporate clients in all health care fraud matters. Our attorneys have extensive experience in matters including, but not limited to:
- Whistleblower Claims (qui tam defense)
- Letters from the U.S. Attorney’s Office
- Civil Investigative Demands (CIDs)
- Grand Jury Subpoenas
- Department of Health and Human Services Office of Inspector General (OIG) Subpoenas
- Requests for Depositions and Subpoenas to Testify in Court
- Medicare and Medicaid Audits
- Centers for Medicare and Medicaid Services (CMS) and State Licensing Board Matters
- DEA and Prescription Investigations
We handle health care fraud investigations and prosecutions involving all substantive legal issues, such as those listed below.
Billing and Coding Fraud
All providers that bill Medicare, Medicaid, Tricare, and other federal health care benefit programs are required to strictly comply with these programs’ billing and coding requirements. Coding errors, even those that are unintentional, constitute “fraud” under federal law – and they can subject providers to severe financial penalties and other consequences. Some of the most-common allegations against providers accused of billing and coding fraud include:
- Double-billing a single benefit program, billing multiple programs for the same service, or billing a benefit program and a private insurer
- Billing for “non-allowable” costs such as operational expenses, or billing for services provided by unlicensed or excluded practitioners
- Billing for services, supplies, and equipment at their stand-alone reimbursement rates instead of the “bundled” rates provided for under the applicable program regulations (referred to as “unbundling”)
- Billing for services, supplies, and equipment at a higher rate than specified under the applicable program regulations (referred to as “up-coding”)
- Billing for services, supplies, and equipment that have not actually been purchased or provided to patients (referred to as “phantom billing”)
Providers facing allegations of billing and coding fraud must be cautious not to simply assume that the government’s allegations are correct. While some federal agents and prosecutors are experts in the Medicare, Medicaid, and Tricare billing regulations, they also make mistakes, and the regulations change over time. Maybe a bill that your office submitted complied with then-current regulations even though it would be considered non-compliant today. Maybe a reimbursement request which appears fraudulent based on data analysis is actually fully legitimate given the unique aspects of your business or practice. There are numerous potential defenses to allegations of billing and coding fraud, and in order to build an effective defense, you need to get out in front of the government’s investigation.
Illegal Kickbacks, Referral Fees, and Physician “Self-Referrals”
As a general rule, it is unlawful to use program-reimbursed funds to pay referral fees, kickbacks, and other forms of remuneration in connection with the provision of health care services or the purchase or lease of equipment, facilities, or supplies. The Anti-Kickback Statute and Stark Law contain broad prohibitions against these types of transactions and financial relationships, and allegations of offering, soliciting, paying, and accepting illegal forms of remuneration are common in comprehensive health care fraud investigations.
The Anti-Kickback Statute applies to all health care providers, and it prohibits any and all forms of compensation. This includes:
- Cash payments
- Discounts for services, supplies, or equipment
- Free or below fair market value use of clinical space, equipment, or staff
- In-kind gifts
- Marketing commissions
- Payments to family members
Unlike the Anti-Kickback Statute, the Stark Law is specific to physicians and entities with which they have a direct or indirect compensation or investment relationship. It also only applies to referrals for “designated health services,” which include:
- Clinical laboratory services
- DME and medical supplies
- Home health services
- Inpatient and outpatient hospital services
- Outpatient pathology
- Outpatient prescriptions
- Parenteral and enteral nutrients, equipment, and supplies
- Physical therapy
- Prosthetics, orthotics, and related supplies
- Radiology and radiological therapy
However, while the Anti-Kickback Statute and Stark Law contain broad prohibitions on compensation arrangements involving payment of program-reimbursed funds, they are subject to numerous safe harbors and exceptions which protect a variety of different types of transactions. In Anti-Kickback Statute and Stark Law investigations, our Seattle health care fraud defense lawyers’ focus is often on demonstrating that one (or more) of these safe harbors or exceptions applies. Some of the safe harbors and exceptions most commonly used by physicians, clinics, and other providers include those that protect:
- Arrangements with hospitals
- Cooperative health service organizations
- Discounts and price reductions
- Group purchasing organizations
- In-office ancillary services
- Indirect compensation arrangements
- Isolated transactions
- Non-monetary compensation
- Personal service arrangements
- Rentals for office space and equipment
“False and Fraudulent” Claims
Billing and coding violations, kickbacks, and physician self-referrals can all be prosecuted as “false and fraudulent” claims under the False Claims Act (FCA). The False Claims Act prohibits any and all improper requests for payment from the government, and it imposes both civil and criminal penalties. Other common allegations against health care providers under the False Claims Act include:
- Billing for medically-unnecessary services, supplies, and equipment. In order to be eligible for reimbursement, a service, supply, or piece of equipment must meet the relevant program’s definition of medical necessity. If a service or item is deemed medically-unnecessary under the applicable program guidelines (even if it may have been reasonably necessary within the course of patient care), billing for the service or item can trigger FCA liability.
- Submitting reimbursement requests based upon falsified patient records. Prosecutors often take aggressive action against providers who they believe to have falsified patient data in connection with a request for Medicare, Medicaid, or Tricare reimbursement. If you (or someone within your business or practice, such as a billing administrator) has been accused of falsifying records, you will need to tailor your defense strategy to combatting these dangerous allegations.
Prescription Drug Fraud
Prescription drug fraud investigations targeting physicians, pharmacists, clinics, and other providers and facilities often involve multiple federal agencies and the potential for severe charges under a variety of federal statutes. Recently, the DOJ formed an Opioid Fraud and Abuse Detection Unit comprised of agents and prosecutors who are specifically tasked with targeting providers suspected of contributing to the wave of opioid abuse and dependence. Compound pharmacy fraud has been a major focus of the federal government’s anti-fraud enforcement efforts as well. Our defense attorneys and former federal prosecutors have extensive experience in prescription drug fraud cases involving allegations such as:
- Dispensing more medication than was prescribed
- Drug shorting and refill schemes
- Falsifying and forging prescriptions
- Illegally importing prescription medications
- Prescribing drugs that are medically-unnecessary
- Prescribing medications without an in-person exam
- Prescription drug diversion
- Selling fraudulent prescriptions
Home Health and Hospice Fraud
The home health and hospice care sectors have seen enhanced scrutiny from federal authorities in recent years as well. While these investigations can involve all of the substantive issues discussed above, they often involve two issues that are unique to home health and hospice care:
- Physician Certification Fraud – Prior to commencing treatment home health agencies and hospices must obtain physician certifications. They must also obtain recertifications for their patients every 60 days. Common allegations in physician certification fraud investigations include falsifying and forging certifications, offering kickbacks and referral fees to certifying physicians, and seeking certifications from physicians other than patients’ primary care providers.
- Election Statement Fraud – In addition to obtaining physician certifications, hospices must also obtain election statements from their patients. Failing to notify patients of their rights (and the fact that electing for hospice care can waive certain of these rights) can lead to allegations of election statement fraud. Other activities such as forging patients’ signatures, backdating election statements, failing to keep adequate records, and refusing to accept patients’ election revocations can lead to these allegations as well..
Seattle Health Care Fraud Defense: Answers to Frequently-Asked Questions (FAQs)
Q: What should I do if I have been contacted by federal authorities regarding my business's Medicare billings?
If you have received an inquiry regarding your Medicare, Medicaid, or Tricare billings (or any other aspect of your health care business or medical practice), it is important that you speak with a Seattle health care fraud defense lawyer immediately. You need to respond appropriately; but in order to do so, you also need to know the answers to questions such as:
- Why is the government looking into your business or practice?
- What type of inquiry have you received (i.e., was it a letter or civil investigative demand (CID))?
- Is the government’s inquiry civil or criminal in nature?
- How long has your business or practice been under investigation?
- What is the scope of the allegations against you, and what are the potential ramifications?
When we represent clients in health care fraud investigations, one of our first steps is to intervene in the investigation in order to obtain answers to the questions we just listed. Armed with this information, we can then begin to help our clients make informed decisions about protecting their legal rights.
Q: What do I need to know about facing an investigation under the False Claims Act?
If your business or practice is being targeted for alleged health care fraud, any charges will most likely include civil or criminal charges under the False Claims Act. To learn more about the risks of being prosecuted under the FCA, you can read:
- 5 Things You Need to Know About the Federal False Claims Act
- Avoiding Criminal Charges in False Claims Act Cases
- False Claims Act & Qui Tam Defense
- What You Should Do When You Are Under a False Claims Act Investigation
Q: What factors should you consider when choosing a health care fraud defense attorney in Seattle?
When choosing an attorney (or team of attorneys) to represent you, the two most important factors are experience and prior results. While prior results do not guarantee future outcomes, a significant record is still highly relevant to choosing the attorney (or attorneys) you want defending you against the government. For more considerations, we encourage you to read: Defending Health Care Fraud: Choosing the Right Lawyer. Choose wisely. Hire one of our skilled and winning Seattle health care fraud defense lawyers.
Contact our Seattle Health Care Fraud Defense Lawyers at Oberheiden, P.C.
If your Seattle health care business or medical practice is under investigation by the DOJ, OIG, DEA or another federal agency or task force, we encourage you to contact us promptly for a free initial consultation. To speak with the Seattle health care fraud defense attorneys on our fraud defense team in confidence, please call (888) 519-4897 or request a case assessment online now.