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When Are Los Angeles Healthcare Fraud Investigations Criminal?

health care fraud criminal investigation

 

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If you have been accused of healthcare fraud or are facing a government investigation into your healthcare business, call the former Department of Justice healthcare fraud prosecutors of Oberheiden, P.C. today to speak to one of our senior attorneys and discuss possible resolutions.  We are available seven days a week, including weekends.  All initial consultations are free and confidential.

Current Healthcare Fraud Investigations in Los Angeles

In the past few years, the federal government has set up specialized task forces to aggressively investigate, monitor, and prosecute Medicare Fraud in nine cities across the nation.  One of those task forces is headquartered in Los Angeles, California.  Therefore, owners of healthcare businesses and medical services providers in Southern California should be aware that healthcare fraud prosecutions will occur more frequently, more publicly, and much more aggressively in their area than in other cities and states.  Medicare Fraud investigations in Los Angeles are led by the Healthcare Fraud Prevention and Enforcement Action Team, known as HEAT, a coordinated effort of law enforcement officers and attorneys from multiple federal agencies, including the Department of Justice (DOJ), the Office of the Inspector General of the Department of Health and Human Services (OIG), and the Federal Bureau of Investigation (FBI).

An Explanation of Healthcare Fraud

Many of our clients come to us with the same initial question: “How do federal prosecutors establish healthcare fraud?”  The answer, simply put, is that healthcare fraud has been committed any time there has been an attempt, successful or not, to obtain money by means of a fraudulent or false representation to any government health program, such as Tricare, Medicare, or Medicaid.  The most common types of healthcare fraud that are pursued by the federal government are:

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden

Founder

Attorney-at-Law

John W. Sellers
John W. Sellers

Former Senior Trial Attorney
U.S. Department of Justice

Local Counsel

Joanne Fine DeLena
Joanne Fine DeLena

Former Assistant U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney & Former District Attorney

Local Trial & Defense Counsel

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Aaron L. Wiley
Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (OIG)

Gamal Abdel-Hafiz
Gamal Abdel-Hafiz

Former Supervisory Special Agent (FBI)

Chris Quick
Chris Quick

Former Special Agent (FBI & IRS-CI)

Kevin M. Sheridan
Kevin M. Sheridan

Former Special Agent (FBI)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

Dennis A. Wichern
Dennis A. Wichern

Former Special Agent-in-Charge (DEA)

  • Anti-Kickback Violations. Under the federal Anti-Kickback Statute, it is illegal for any person, including marketers, contractors, distributors, healthcare providers, or business owners, to receive any form of payment or remuneration in return for referring a patient to a provider or business. Notably, it is illegal not only to receive cash for a referral but also to receive anything having monetary value.
  • Stark Law. Under the Stark Law, it is unlawful for doctors to refer their patients to certain types of healthcare businesses, such as toxicology laboratories or pharmacies, which are owned in whole or in part by the doctors themselves or one of their immediate family members. The same prohibition applies to businesses in which the doctor or a family member has an investment interest or with which the doctor has a compensation agreement.  Importantly, the Stark Law contains certain enumerated exceptions, although these exceptions must be carefully analyzed to ascertain whether they apply to a given situation.
  • False Claims Act Violations. Because the False Claims Act imposes liability for any misstatement of fact made to any federal agency, any billing error may lead to a prosecution under this statute, even if the error was accidental.  Such unintentional errors are only subject to civil penalties, but the federal government will not hesitate to seek criminal fines and incarceration under other healthcare fraud statutes if it believes that the misstatements of fact were intentional.
  • Prescription Fraud. Recently, there has been an increased awareness of the growing number of Americans suffering from substance abuse problems, much of which is related to prescription pain medication. As a result, the government is currently hyper-focused on prescription drug fraud, including both violations of the Drug Enforcement Agency’s guidelines for dispensing medicine and insurance fraud committed by writing prescriptions for medicine that is not medically necessary.
  • Billing Fraud. Errors in billing are one of the government’s most common reasons for initiating a healthcare fraud investigation.  Most billing errors result from a misunderstanding of billing codes or human error, but such errors can nonetheless provide the impetus for an audit or prosecution if the government identifies them.  Billing fraud includes up-coding, bundling, and unbundling, all of which are methods of manipulating the billing codes to increase reimbursement.  Other types of billing fraud include submitting invoices for “ghost patients” (patients who do not exist or were never treated) and “phantom billing” (charging for services that were never performed).
  • Certification Errors. One of the most recent phenomena in healthcare fraud prosecution is the increased emphasis on the hospice and home healthcare industries. Frequently, federal prosecutors focus on allegations that medical providers provide false certifications for healthcare services, wherein a physician avers that the patient is either homebound or terminally ill when that is not actually the case.

At Oberheiden, P.C., our record of avoiding criminal charges for our clients is hard to beat. If you suspect that either you or your healthcare business is under investigation by the federal government, time is of the essence. Call and speak to one of our senior attorneys today. All initial consultations are free and confidential.

When Is Healthcare Fraud Criminal?

The federal prosecutor has the discretion to decide whether to bring a case civilly or criminally. Given the overall rise in the cost of healthcare as well as the number of Americans who are now covered, in whole or in part, by a government health plan, the United States federal government treats healthcare fraud as a serious offense costing the taxpayers hundreds of millions of dollars per year.  Healthcare fraud carries both civil and criminal penalties, and it is up to the prosecutors to determine which type of case to bring.  Civil penalties may include fines, repayment of wrongfully paid invoices, orders for non-payment of future claims, and exclusion from federal healthcare programs.  Criminal penalties are even more serious and may include fines as well as incarceration:  up to ten years in prison for each instance of healthcare fraud, which is increased to a sentence of up to 20 years for each instance that caused serious bodily injury to the patient and up to life in prison if the patient died.  See 18 U.S.C. §1347.

One of the ways we help our clients who are targeted by healthcare fraud investigations avoid criminal charges is by intervening on their behalf early on in the investigation.  If you have been contacted by federal investigators, or if you even just suspect that you are being investigated for healthcare fraud, you should hire an experienced healthcare fraud defense attorney as soon as possible.

Call Oberheiden, P.C. today to speak to one of our former federal prosecutors or experienced defense attorneys.  We can develop an immediate action plan on your behalf.

The government may not reveal whether they are seeking civil or criminal penalties during the initial stages of a healthcare fraud investigation.  Although many people mistakenly believe that every case filed by a U.S. Attorney or an Assistant U.S. Attorney (AUSA) is criminal, the U.S. Attorney’s Office contains both civil and criminal divisions and both sides are staffed by federal investigators and AUSAs.  As such, the fact that you have receive a letter from the Department of Justice or a phone call from an FBI agent does not necessarily indicate that you are under criminal investigation.  Importantly, a case that starts as a civil investigation may turn into a criminal prosecution if an incorrect defense strategy is employed.

Determining whether a federal healthcare fraud case is civil or criminal may require interpretation of document requests and subpoenas, analysis of the tone of the agents who contact witnesses and targets, or investigation into the nature of the allegations made, all of which require experienced and knowledgeable attorneys.  Certain characteristics do indicate that an investigation is likely to be criminal in nature, including involvement of the IRS, issuance of grand jury subpoenas, receipt of target letters, execution of search warrants, seizures of property, issuance of arrest warrants, and involvement of criminal prosecutors.

If you want to know more about the differences between criminal and civil investigations, call Oberheiden, P.C. today.  We represent healthcare clients ranging from complete hospital systems to individual providers.

What Will Happen to Me?

Given the severity of the possible penalties, it is understandable that our clients typically want to hear the worst-case scenario up front. Of course, every case is different, but, in general, the prosecutor’s decision between pursing a civil or criminal case will turn on factors such as motivation, intent, amount of money involved, harm to patients, and the government’s interest in the particular healthcare industry involved or the specific facts of the case.  At Oberheiden, P.C., our unique ability to offer our clients a team of former federal prosecutors and renowned healthcare fraud defense attorneys allows us to regularly avoid criminal prosecutions for our clients.

If you suspect or know that either you or your healthcare business is under investigation by the federal government, time is of the essence. Talk to one of our senior attorneys today.  All initial consultations are free and confidential.

Defending Healthcare Fraud

Oberheiden, P.C. is a different kind of law firm: Our attorneys have decades of experience in the area of healthcare fraud defense, and our attorneys have collectively tried hundreds of jury and non-jury cases in courts across the country.  The Oberheiden, P.C. healthcare fraud defense team includes several former Assistant U.S. Attorneys who were in charge of audits, investigations, and prosecutions of healthcare fraud cases at the Department of Justices.  Our unique team of former prosecutors and experienced criminal defense attorneys offers to our clients the benefit of their skills, insight, and expertise.  Among the advantages you will realize by hiring Oberheiden, P.C. are:

  • Immediate Involvement. Our experience in the arena of healthcare fraud investigations has taught us that the likelihood of avoiding criminal charges is greatly enhanced by early attorney involvement in the investigation and immediate deployment of a carefully planned defensive strategy. Unfortunately, many criminal defense attorneys do not share the same sense of urgency.  At Oberheiden, P.C., we believe that there is simply no time to waste when our clients’ healthcare business, medical practice, money, and even freedom on the line.  We pride ourselves in answering our clients’ most pressing questions within hours of being engaged, including questions regarding the nature and focus of the investigation, how long the investigation may take, what is the likely outcome of the investigation, and what is the basis of the government’s belief that someone has committed healthcare fraud.
  • Focus on Lack of Intent. In every criminal case, the Constitution requires that the government prove each and every element of the crime beyond a reasonable doubt.  Therefore, in order for the government to prevail on charges of criminal healthcare fraud, it must be able to prove beyond a reasonable doubt that the defendant had the requisite criminal intent. At Oberheiden, P.C., we take this standard very seriously and hold the government to its strict burden of proof in every case in which criminal charges are threatened.  For example, billing errors are a common basis for healthcare fraud cases, and the government often sees such errors as demonstrative of malicious intent or ill-will. But we know that most billing errors are caused by simple mistakes, untrained staff, or inadequate supervision.  In such cases, we have successfully avoided criminal charges for our clients on multiple occasions by showing the government that the errors at issue were accidental and demonstrating that our client had no intent to defraud.  As we see it, criminal liability should not be premised on a mistake.
  • Sophisticated Defenses. Not only are we trial lawyers, we are veteran healthcare lawyers as well. Therefore, we have the expertise in healthcare law to interpret and apply legal loopholes and statutory exceptions as well as the ability to win both at the negotiation table and in court.  Our accumulated knowledge has made the difference for our clients in many different types of healthcare fraud cases.  For instance, we have successfully relied on the statutory exceptions contained in the Stark Law to lessen and even eliminate cases against our clients.
  • Protecting Your Reputation. Although our legal analysis and tactics compose the bulk of our defensive strategy, we also understand the effect that unfounded accusations can have on your business and your professional life. We are committed to defending our clients not just in the courtroom but also in the court of public opinion. We understand your fears about how your reputation will be affected by public perception and media reporting.  We have frequently intervened on our clients’ behalf to mitigate libelous reporting, and we have also cultivated relationships with local and national news outlets that we can rely on to tell our side of the story.

Our attorneys appear in courts in Los Angeles, throughout California, and across the country to defend clients against allegations of healthcare fraud. If you are facing a healthcare fraud investigation, call us today for a free, confidential consultation regarding your legal issues.

Our Track Record

At Oberheiden, P.C., our primary goal is to protect our clients’ businesses from government interference and, most importantly, to prevent criminal charges.  Our team of former federal prosecutors and experienced criminal defense attorneys provides elite healthcare fraud defense to clients in all areas of the healthcare industry, including laboratories, pharmacies, hospices, home healthcare agencies, business owners, physicians, hospitals, lawyers, and healthcare executives. Our recent successes for these clients include:

  • Representation of a Pharmacy Investigated by the Department of Defense and the Office of Inspector General for Tricare Fraud.
    Result: No civil or criminal liability.
  • Representation of a Marketing Group Investigated by the Department of Defense and the Office of Inspector General for Tricare Fraud.
    Result: No civil or criminal liability.
  • Representation of Physicians Investigated by the Department of Defense and the Office of Inspector General for Tricare Fraud.
    Result: No civil or criminal liability.
  • Representation of Laboratory against an Investigation by the Department of Justice and the U.S. Attorney’s Office for Alleged Medicare Fraud.
    Result: No civil or criminal liability.
  • Representation of Laboratory against an Investigation by the Department of Health and Human Services and the U.S. Attorney’s Office for Alleged Medicare Fraud.
    Result: No civil or criminal liability.
  • Representation of Laboratory against an Investigation by the Department of Justice and the U.S. Attorney’s Office for alleged Tricare Fraud.
    Result: No civil or criminal liability.
  • Representation of a Healthcare Services Company against an Investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for Alleged False Claims Act and Stark Law Violations.
    Result: No civil or criminal liability.
  • Representation of a Healthcare Marketing Group Against an Investigation by the Office of Inspector General for Alleged Healthcare Fraud.
    Result: No civil or criminal liability.
  • Representation of a Physician against an Investigation by the Department of Health and Human Services and the U.S. Attorney’s Office for Alleged Medicare Fraud, Stark Law Violations, and Anti-Kickbacks.
    Result: No civil or criminal liability.
  • Representation of Laboratory against an Investigation by the Department of Justice and the Office of Inspector General for Alleged False Claims Act and Medicare Violations.
    Result: No civil or criminal liability.
  • Representation of Physician Investigated by the Department of Justice and the Office of Inspector General for Medicare Fraud and False Claims Act Violations.
    Result: No civil or criminal liability.
  • Representation of Physician Investigated by the Office of Inspector General for Medicaid Fraud and Stark Law Violations.
    Result: No civil or criminal liability.
  • Representation of Healthcare Organization Investigated by the Department of Justice and the Office of Inspector General for Medicare Fraud.
    Result: No civil or criminal liability.
  • Representation of Physician Group Investigated by the Department of Justice and the Office of Inspector General for Medicare Fraud, Stark Law Violations, and False Claims Act Violations.
    Result: No civil or criminal liability.
  • Representation of Physician Group Investigated by the Department of Health and Human Services and the Office of Inspector General for False Claims Act Violations.
    Result: No civil or criminal liability.
  • Representation of a Physician Investigated by the Department of Defense and the Office of Inspector General for Tricare Fraud.
    Result: No civil or criminal liability.
  • Representation of Pharmacy Investigated by the Department of Justice and the Office of Inspector General for Department of Labor Program Fraud.
    Result: No civil or criminal liability.

Contact us today and speak directly to one of our experienced attorneys. We are available to discuss your situation in a free and confidential conversation seven days a week, including weekends.

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Including WeekendsOberheiden, P.C.
Serving Los Angeles, CA and Surrounding Areas
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Not all attorneys of Oberheiden, P.C. are licensed in California and nothing contained in here is meant to constitute the unauthorized practice of law.

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