Plano Healthcare Fraud
Knowledgeable Healthcare Fraud Defense Lawyers Representing Medical Professionals and Businesses in PlanIf you are a doctor or other medical provider in Plano or the surrounding areas of Collin County or Denton County, the possibility that you will find your practice or business engulfed in a federal investigation has never been higher. Governments at the local, state, and federal level are aggressively pursuing actions for reimbursement of the public costs of prescription drug abuse. Further, the United States Department of Justice along with other federal agencies pursue massive qui tam and whistleblower actions based on allegations of defrauding public health programs like Medicaid and Medicare. This focus on pursuing civil and criminal sanctions against parties purportedly engaged in Plano healthcare fraud threatens to swallow up providers of medical care and services for relatively innocent acts and honest mistakes. If you operate a medical practice or business that provides services in the health sector of the economy, the mere specter of a federal investigation, grand jury indictment, civil qui tam action, or criminal prosecution can be devastating. As a physician or other medical provider, we recognize your professional and business reputations are valuable assets that can be easily damaged by this sort of scrutiny from government regulators.
Experienced Former Federal Prosecutors Advocating for Healthcare Professionals in North TexasOur local North Texas healthcare fraud defense attorneys at Oberheiden, P.C. understand that the career of a physician, pharmacist, or another medical provider could be irreparably damaged by the negative impact of allegations of fraud or other misconduct. We understand the threat to the reputation of your medical practice or health business, which is why our law firm focuses on quashing legal actions against our clients before they get started. Our law firm has built a national reputation for delivering aggressive representation and providing sound legal advice to members of the medical community and healthcare industry companies before a grand jury returns an indictment. When retained early in the process, our goal is not to simply prevail in your criminal case once you are embroiled in a criminal prosecution. Rather, we strive to keep you from facing formal charges in federal court. Health industry providers and professionals choose Oberheiden, P.C. because of our experience and proven results:
- Former Justice Department Lawyers
- Former Federal Healthcare Fraud Prosecutors from the U.S. Attorney’s Office
- Significant Experience with Healthcare Fraud Cases in Collin County and the Eastern District of Texas
- Locally Available, Including on Weekends
Overview of the Medicaid and Medicare Fraud Investigation ProcessFederal law enforcement agencies have partnered with state and local law governments to uncover and punish healthcare fraud schemes. Tenacious investigation tactics often include the use of confidential informants, such as disgruntled ex-employees, and others with intimate knowledge of the medical practice company to facilitate the investigation and pursuit of criminal charges. This intense scrutiny along with rewards offered to whistleblowers often result in simple negligence or incidental errors being reported as fraud. If you are frequently involved in billing Medicare/Medicaid, you know that the billing procedures in the manuals are complicated so that coding errors and other understandable mistakes occur. Because of the influx of financial resources to prosecute fraud under federal statutes, health professionals often find they are forced to endure intrusive investigations. When navigating a Medicaid/Medicare audit, healthcare professionals need an attorney with knowledge of Centers for Medicare and Medicaid Services (CMS) regulations, as well as experience handling cases involving state and federal fraud laws. Health fraud allegations might target many types of conduct, which include the following:
- Billing for ghost patients
- Illegal kickbacks
- Billing services individually when they should be grouped under a code (Unbundling)
- Medical procedures or prescriptions that are not medically necessary
- Billing for a more expensive service than that performed (Up coding)
- Submitting false claims to CMS
- Billing for services from excluded providers
- Performing excessive services or procedures (Overutilization)
- Giving false statements on applications or contracts for participation in Medicaid/Medicare
- Billing for equipment or services not provided
Recovery Audit Contractors (RACs)RAC audits analyze claims that are submitted to identify under and overpayments. Companies that perform these audits typically are compensated on a contingency-fee basis, so these contractors are strongly incentivized to find overpayments. This form or audit has been expended to Medicare Advantage (Part C), Prescription Drug Plans (Part D), and Medicare Advantage (Part C).
Comprehensive Error Rate Testing Program (CERTs)The primary focus of CERT is to determine a general error rate but the information is forwarded to the carrier or MAC.MAC will use the information to pursue recovery of overpayments.
Zone Program Integrity Contractors (ZPICs)While MAC auditors primarily focus on uncovering and preventing errors, within a ZPIC audit, the auditors focus on potential healthcare fraud. Providers will be required to submit documentation. Payment frequently will be held up until the completion of an appeals process. Many ZPIC audits are triggered by referrals from RAC and MAC contractors. ZPIC contractors might receive leads triggering closer scrutiny through a variety of sources, such as medical reviews, data mining appeals, audit and reimbursement, enrollment, and claims review.
Medicare Administration Contractors (MACs)These contractors are contracted for a range of purposes, such as handling billing errors when services are improperly coded or not covered. MACs also identify “outliers” based on analysis of provider data. Based on this analysis, these contractors often schedule probe audits of flagged providers. The auditors scrutinize claims to modify or deny payments if he or she decided they are not medically necessary or reasonable. The reviewer also will look for payments that are made for services not actually provided by the individual or entity submitting the bill.
Federal Investigations and Prosecutions in Plano & Collin CountyFederal health fraud charges that lead to civil or criminal liability may originate from a wide array of agencies that include the United States Department of Health and Human Services Office of the Inspector General, United States Department of Justice, Drug Enforcement Administration, Department of Labor Employee Benefits Security Administration, United States Postal Service Office of the Inspector General, Department of Defense (Tricare), Criminal Investigations Division Internal Revenue Service, and Federal Bureau of Investigation. Our dedicated and proven Plano healthcare fraud attorneys have the expertise to defend physicians and health businesses under the specter of a federal investigation, federal grand jury, federal prosecution, or federal subpoena. Whether you are under investigation or the target of a returned grand jury indictment, our law firm has a long successful history of preventing medical professionals and health industry companies from civil and criminal liability. The dizzying number of federal agencies that might be involved in a federal investigation for health fraud violations is matched by the many legal grounds for pursuing healthcare entities and individuals. Some of the most common tools of regulatory enforcement include:
False Claims Act (31 U.S.C. 3720-3733The federal False Claims Act in the health context forbids tendering a false claim for payment to a benefits program like Medicaid, Medicare, and Tricare. Physician practice groups and other health providers can be subject to significant civil damages and penalties under the federal statute. By way of example, Olympus Corp. was forced to pay 310.8 million to settle a claim under the law several years ago. Healthcare related billing practices that involve Medicare and that are forbidden by the FCA include the following:
- Causing a false or fraudulent claim to be presented
- Conspiring with others to induce the federal government to pay a false claim
- Presenting a fraudulent or false claim
- Using or causing to be used a false statement or false documentation to obtain federal payment of a claim
Stark Law (42 U.S.C. 1395nn) & Anti-Kickback Statute (42 U.S.C. 1320a-7b)The physician self-referral prohibition (Stark Law) and Anti-Kickback Statute (AKS) target medical entrepreneurs and doctors engaged in relationships that might generate medical referrals, or the provision of health services, for reasons of financial gain rather than therapeutic value. The laws impose harsh civil and criminal penalties for a broad spectrum of practices related to Medicaid and Medicare-reimbursed healthcare benefit programs. The Stark Law prohibits payments to doctors who refer patients to medical providers with whom the physician has a financial relationship or interest. While a violation of the Stark Law can result in significant fines, our Plano Stark law defense attorneys often successfully apply exceptions and safe harbor provisions to defend clients. Similarly, the AKS statute imposes criminal penalties for willfully and knowingly soliciting, offering, receiving, or paying for business billed to Medicare and Medicaid. The employment relationship exception also applies to the AKS. Our lawyers are thoroughly versed in all of the relevant safe harbors and expectations. For example, when a “bona fide” employment relationship exists between the physician and the entity or individual to whom the patient was referred, this can provide a defense if the employer pays fair market compensation.
Medicaid Fraud (18 U.S.C. 1347)The healthcare fraud law prohibits knowingly and willingly executing an artifice or scheme to obtain money or property using false representations, promises, or pretenses from a health benefit program. A violation can result in 10 years in federal prison and a fine, or both.
Frequently Asked Questions from Medical Industry Providers Targeted for Healthcare Fraud Investigations and Prosecutions in Texas
Can assets of a physician be seized based on an allegation of healthcare billing fraud?
When a doctor or other healthcare individual or entity is arrested for fraud under a federal statute, such as the Stark Law or the Anti-Kickback Statute, the government might freeze the individual’s or company’s bank accounts. The government ostensibly takes this action, so the funds ultimately can be seized if they are the fruits of the unlawful activity. However, the more salient consequence is that the loss of access to this money is designed to impose financial pressure on an accused to accept an unfavorable guilty plea. Even if the government cannot prove that the actual assets frozen were the profits of criminal activity, the state will still seek to have equivalent funds seized under a “substitute asset” theory. The government also can seize other property such as real estate, vehicles, jewelry, etc. You should call Oberheiden, P.C. immediately if you have questions about how to legally avoid some of the consequences of forfeiture or seizure in a health fraud investigation.
What types of cases do you handle against healthcare professionals?
Our healthcare fraud attorneys who handle cases in Plano and throughout Northern Texas provide an effective defense in cases involving health professionals to clients facing a broad range of allegations that include but are not limited to the following:
- Taking part in financial relationships that constitute an impermissible conflict of interest
- Receiving or providing financial inducements like kickbacks
- Billing for medical services not furnished
- Unlawful marketing of drugs and medical devices
- Double billing for legal services
- Making false claims to government insurance benefit plans
- Billing for medical services that are not medically necessary
What should I do if I am under investigation by the federal government?
The best way to prepare for a federal investigation or a Medicare audit is to seek compliance advice from an experienced Plano healthcare fraud attorney BEFORE you become the target of an audit. Our experienced team works with industry experts, so we can review your billings and assist you in identifying and eliminating errors and developing procedures that promote compliance. If you have been contacted about an audit or investigation, you should seek prompt legal advice and speak to an experienced healthcare fraud defense attorney as soon as possible.
What types of providers and companies get investigated for improper billing and other forms of healthcare fraud?
Whether you are a physician or virtually any business engaged in the health industry, you can come under the scrutiny of a healthcare audit or federal investigation. Some of the parties that have faced health fraud allegations include:
- Physician Practice Groups
- Mental Health Groups
- Psychiatrists and Psychologists
- Home Health Agencies
- Hospice Agencies
- Physical Therapy Clinics
- Drug Treatment Centers
- Imaging Centers
- Nursing Homes
- Equipment Vendors
- Healthcare Marketers