Formed in October 2018, the Appalachian Regional Prescription Opioid Strike Force (ARPO Strike Force) is one of many federal authorities targeting West Virginia health care providers in Medicare fraud investigations. If your business or practice is under investigation, it is important that you engage legal representation promptly.
Medicare fraud investigations can lead to recoupments, fines, program exclusion, prison time, and other penalties. For West Virginia health care providers targeted in these investigations, presenting a comprehensive and strategic defense needs to be a top priority. At Oberheiden, P.C., the attorneys on our federal health care fraud defense team have centuries of combined experience in Medicare fraud investigations, and we have a proven record of success helping our clients avoid federal charges.
Our federal health care fraud defense team is comprised entirely of nationally-renowned defense attorneys and former federal prosecutors. This includes attorneys who have worked within the U.S. Department of Justice (DOJ) and the U.S. Attorney’s Office, and who have worked with agents from all relevant federal agencies to investigate and prosecute health care providers suspected of Medicare fraud. As defense counsel, our attorneys rely on this past experience to interpret and anticipate the government’s actions during Medicare fraud investigations, and our team approach ensures that all clients have the benefit of our attorneys’ collective knowledge and insights on their side.
Federal Defense Attorneys for West Virginia Medicare Fraud Cases Involving All Investigating Agencies
When facing a Medicare fraud investigation, prompt intervention and an aggressive defense strategy are key to mitigating or eliminating any potential consequences. When you engage our firm to represent you, our attorneys will begin working on your case immediately. We will work closely with you to understand the facts at hand, and we will use our in-depth knowledge of the federal Medicare enforcement system to execute a defense strategy designed to secure a favorable result as efficiently and discretely as possible.
We have experience in Medicare fraud investigations involving all relevant federal agencies, including:
- Centers for Medicare and Medicaid Services (CMS)
- Department of Justice (DOJ)
- Department of Health and Human Services Office of Inspector General (OIG)
- Drug Enforcement Administration (DEA)
- Federal Bureau of Investigation (FBI)
- Internal Revenue Service (IRS)
Many investigations also involve the Medicare Fraud Strike Force, and specifically the Appalachian Regional Prescription Opioid Strike Force (ARPO Strike Force) which focuses on targeting health care providers in West Virginia and throughout the Appalachia region. These strike force teams include agents and prosecutors from the DOJ, OIG, FBI, and other state and local law enforcement agencies, and they devote 100% of their time and resources to securing civil penalties and criminal convictions for billing and coding violations and other forms of Medicare fraud.
Defending Against Common Medicare Fraud Allegations
1. Common Medicare Fraud Allegations
Although every case is different (and when we defend health care providers, we focus on the unique aspects of their cases to develop custom-tailored defense strategies), most Medicare fraud investigations tend to focus on the same general types of allegations. Understanding not only the legal basis for these allegations but also why your business or practice in particular is being targeted is critical to asserting a successful defense. Some of the most-common allegations against health care providers in Medicare fraud investigations include:
- Phantom Billing – Billing for services or supplies not actually provided to patients or durable medical equipment (DME) not actually purchased.
- Upcoding – Billing for services, supplies, or equipment at a rate higher than the rate prescribed by the Medicare billing guidelines.
- Unbundling – Billing for services and supplies at their individual rates rather than a reduced “bundled” rate prescribed by the guidelines.
- Double–Billing – Billing Medicare twice for the same service or item or billing Medicare and another health care benefit program (such as Medicaid or Tricare) and a private insurer.
- Lack of Medical Necessity – Billing for services that do not qualify as “medically necessary” under the guidelines.
- False and Fraudulent Claims – Inflating charges, falsifying patient records, misrepresenting test results, and making unnecessary use of testing machines and other DME.
- Prescription Drug Fraud – Diverting prescription medications, overfilling or underfilling prescriptions, prescribing unnecessary medications, and forging prescriptions for opioids and other drugs.
- Kickbacks and Referral Fees – Offering, soliciting, paying, or accepting any referral fee, rebate, or other form of “remuneration” in violation of the Anti-Kickback Statute or the Stark Law.
In terms of why federal authorities may have chosen to specifically target your business or practice, there are a few likely factors. In most cases, the decision to target a particular Medicare-participating provider is the result of either:
- An unfavorable determination following a ZPIC, RAC, or MAC audit;
- Apparent “anomalies” in the provider’s billing data as identified by the government’s automated data analytics software; or,
- A whistleblower claim filed by a competitor, patient, or disgruntled former employee.
2. Potential Defenses to Medicare Fraud
There are numerous potential defenses to Medicare fraud allegations. The specific defenses available in any particular case will depend upon the specific allegations involved and whether those allegations are civil or criminal in nature. When we represent health care providers accused of Medicare fraud, we routinely on defenses such as:
- Burden of Proof – In all cases, the federal government has the burden of proof. If we can identify shortcomings in the government’s evidence with respect to any of the individual elements of an alleged offense, then we should be able to prevent a conviction at trial.
- Lack of Intent – In criminal Medicare fraud cases, federal prosecutors must prove that the defendant subjectively intended to overbill the government, improperly prescribe or dispense medications, or engage in an unlawful referral transaction. If there is no evidence to prove that you intentionally violated the law, then you do not deserve to be burdened with a criminal record.
- Safe Harbors – Under the Anti-Kickback Statute and the Stark Law, many different types of transactions will qualify for safe harbor Successfully asserting these statutory safe harbors can insulate providers from both civil and criminal charges.
- Unlawful Searches, Seizures, and Interrogations – If federal authorities obtained any evidence in violation of your Fourth, Fifth, or Sixth Amendment constitutional rights, then that evidence should be deemed inadmissible in your case. Without admissible evidence federal prosecutors should not be able to obtain a conviction in court.
- Partial Defenses – In cases where it is not possible to entirely avoid prosecution, our attorneys work to minimize our clients’ exposure to the greatest extent possible. This could mean ensuring that an investigation remains civil in nature rather than criminal, or ensuring that a criminal charge does not lead to incarceration.
3. Possible Outcomes in Medicare Fraud Investigations
When assessing your exposure as a result of being targeted by the DOJ, OIG, ARPO Strike Force, or any other federal authority with jurisdiction over Medicare fraud matters, it is necessary to critically assess the veracity of the government’s allegations, the evidence that is available to support those allegations, and your likelihood of success if you were to present a defense at trial. This assessment should be done as early in the process as possible, and health care providers should be constantly re-assessing their potential exposure as their investigations unfold. Depending upon the circumstances involved, a successful result could mean:
- 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
5 Reasons to Choose Oberheiden, P.C. in West Virginia
With the potential for substantial financial penalties, loss of Medicare eligibility, state licensing board action, and even federal imprisonment, West Virginia health care providers targeted in Medicare fraud investigations must take their circumstances extremely seriously. This means knowing how to avoid dangerous mistakes, executing a comprehensive and proactive defense strategy, and pursuing all available means to convince federal prosecutors not to press charges. At Oberheiden, P.C., we have a proven record of success in Medicare fraud investigations, and we are trusted defense counsel for health care providers in West Virginia and nationwide.
When you choose Oberheiden, P.C. for your Medicare fraud investigation in West Virginia:
- Our nationally-renowned defense attorneys and former federal prosecutors will work as a team to build the strongest possible defense.
- Our attorneys will call upon their vast experience on both sides of Medicare fraud investigations to provide strategic and custom-tailored legal representation.
- You will have direct access to our senior attorneys who you will be able to reach by phone, text, and email 24/7 throughout the duration of your case.
- We will aggressively intervene in the government’s investigation and continually apply pressure based upon sound defense tactics and a comprehensive understanding of the legal and medical issues involved.
- We will ensure that you feel confident and informed at every stage of the process, and we will carefully advise you regarding potential outcomes as opportunities for resolution arise.
Contact Us for a Free Case Assessment
To speak with a member of our federal health care fraud defense team about your West Virginia Medicare fraud investigation, call us 24/7 at 888-519-4897 or contact us online. Our attorneys are available to begin working on your case immediately.