If your Wisconsin health care business or medical practice is under investigation, executing a proactive defense strategy can significantly mitigate your risk of civil or criminal prosecution. To speak with a member of our federal health care fraud defense team in confidence, call 888-519-4897 now.
Federal authorities are targeting health care providers in Wisconsin. If you treat patients, perform testing, dispense medications, or sell medical equipment or supplies, you are at risk of being targeted, and this means that you are at risk for severe civil or criminal penalties.
In recent years, health care fraud has become a top federal law enforcement priority. This includes fraud targeting Medicare, Medicaid, Tricare, and the Department of Labor (DOL), as well as fraud involving the prescription and distribution of opioid medications. Agencies from the Drug Enforcement Administration (DEA) to the Department of Health and Human Services’ Office of Inspector General (OIG) are targeting all types of health care providers with intensive and aggressive investigations, and providers who fail to defend themselves are at risk for penalties ranging from civil recoupments to long-term federal imprisonment.
Federal Health Care Fraud Defense Attorneys Serving Wisconsin Providers
At Oberheiden, P.C., our federal health care fraud defense team provides legal representation for physicians, pharmacists, and other health care providers in Wisconsin and nationwide. Our team includes nationally-recognized defense attorneys and former Department of Justice (DOJ) prosecutors, and we have successfully represented clients faced with allegations of virtually all types of health care fraud. Examples of our success include:
- Avoiding referrals to the U.S. Attorney’s Office as a result of health care audits.
- Protecting the substantial majority of our clients against criminal charges.
- Dismissing criminal indictments for federal health care fraud.
- Resolving numerous investigations with the result of no civil or criminal liability for our client.
Meet the federal health care fraud defense team at Oberheiden, P.C.
Experience Representing Health Care Providers in Wisconsin and Nationwide
Our health care fraud defense practice consists of representing patient-facing providers, suppliers, and other entities that bill federal health care benefit programs that are facing civil and criminal fraud allegations. This includes allegations under the Anti-Kickback Statute, the Controlled Substances Act, the False Claims Act, the Stark Law, the federal health care fraud statute, and various other federal laws, and it includes investigations and prosecutions involving the DEA, DOJ, OIG, and other federal agencies and task forces.
While all cases are unique and require a defense strategy that is custom-tailored to the particular factual and legal circumstances involved, most cases involve some variation on one or more of the following:
10 Common Allegations in Federal Health Care Fraud Cases
1. Billing and Coding Errors
Common billing and coding-related allegations include double-billing, unbundling, upcoding, and other uses of incorrect billing codes. Depending upon the circumstances involved, allegations of billing and coding errors can lead to either civil or criminal charges.
2. Kickbacks, Bribes, and Rebates
Kickbacks, bribes, rebates, and other forms of “remuneration” are prohibited when they are paid in exchange for referrals of program-reimbursed services, equipment, or supplies. These allegations can also be civil or criminal in nature, with evidence of intent being the key differentiating factor between civil and criminal cases.
3. Physician Self-Referrals
Self-referrals involve referrals between physicians and their “related entities” (entities with which physicians have a financial relationship or in which they own a financial interest). The Stark Law prohibits self-referrals for “designated health services” reimbursed by Medicare or Medicaid, and it imposes civil penalties which include fines, recoupment, treble damages, pre-payment review, and program exclusion.
4. False and Fraudulent Claims
False and fraudulent claims are at the center of most federal health care fraud investigations. The prohibition on false and fraudulent claims exists under the False Claims Act, which allows for civil or criminal prosecution of providers that improperly bill Medicare, Medicaid, Tricare, or the DOL.
5. Billing for Medically-Unnecessary Services, Supplies, or Equipment
If a service, supply, or piece of equipment does not qualify as medically-necessary under the applicable program billing guidelines, then it is not eligible for reimbursement. Billing for medically-unnecessary, services, supplies, or equipment can lead to civil or criminal charges under the False Claims Act.
6. Billing for Services, Supplies, or Equipment Not Provided
Billing for services, supplies, or equipment not provided (so-called “phantom billing”) can trigger prosecution under the False Claims Act as well. This includes intentional fraudulent reimbursement claims as well as mistaken reimbursement requests resulting from administrative mistakes and other honest human errors.
7. Prescription Drug Fraud
Prescription drug fraud includes diversion, forging prescriptions, improperly filling prescriptions, and all other means of getting controlled-substance medications into the hands of individuals to whom they have not been prescribed. Prescription drug fraud investigations can lead to criminal prosecution with the potential for severe penalties under the Controlled Substances Act.
8. Falsifying Patient Records and Inaccurately Reporting Test Results
Allegations of falsifying patient records or test results may be justified, or they may result from a misinterpretation of a provider’s methodologies or record-keeping practices. We have extensive experience in this area, and our attorneys have successfully represented clients against a broad range of civil and criminal allegations.
9. Fraudulent Physician Certifications and Election Statements for Hospice Care
Hospice fraud is a subarea of health care fraud that often involves allegations related to physician certifications and patient election statements. Each of these forms of documentation is subject to strict federal oversight, and our attorneys are intimately familiar with the regulations that apply to program-reimbursed hospice care.
10. Health Care Fraud Attempt and Conspiracy
Federal prosecutors can pursue criminal charges for attempt and conspiracy under a broad array of circumstances, including circumstances in which no fraudulent billings have actually been submitted. Defending against charges of attempt or conspiracy requires a case strategy that is specifically-tailored to the factual circumstances and legal allegations at hand.
FAQs: Defending Against Federal Health Care Fraud Investigations in Wisconsin
Q: How do I know if my investigation is civil or criminal in nature?
Determining whether a federal health care fraud investigation is civil or criminal in nature can be challenging, but it is also a critical first step toward building an effective defense strategy. In addition to identifying the agency (or agencies) handling your investigation and examining the types of requests for information you have received from these agencies (i.e. civil investigative demands or grand jury subpoenas), our attorneys can promptly make contact with the federal agents handling your case to determine the scope and nature of the allegations against you.
Q: What should I do if I have been contacted by the DEA, DOJ, OIG, or another federal agency?
If you (or any other individual in your business or practice) has been contacted by federal agents or prosecutors, it is imperative that you speak with a defense attorney as soon as possible. There are important steps you need to take and critical mistakes you need to avoid, and engaging legal counsel quickly can significantly reduce your risk of prosecution.
Q: How are civil and criminal cases different?
There are numerous legal differences between civil and criminal cases. However, the most-significant difference is the potential penalties involved: While providers targeted in civil cases are at risk for significant financial liability and program exclusion, in criminal cases providers can also face federal imprisonment.
Q: What should I do if I am aware of billing errors or deficiencies in my practice’s compliance program?
This can be a delicate situation, as health care providers have an obligation to proactively address known violations in many cases. When you speak with an attorney, you should be sure to ask about the potential implications involved in failing to report billing mistakes of which you are aware.
Additional Resources for Wisconsin Health Care Providers
When facing a federal health care fraud investigation, the more you know, the better. Here are five additional resources for health care providers prepared by the experienced federal defense attorneys at Oberheiden, P.C.:
- Glossary: Understanding Your Federal Health Care Fraud Investigation – Learn about some of the key legal terms involved in health care fraud investigations.
- Q&A with Federal Health Care Fraud Defense Lawyer, Nick Oberheiden, PhD: What Do You Need to Know If Your Practice Is Under Investigation? – Learn the answers to more frequently-asked questions in this Q&A with firm founder Dr. Nick Oberheiden.
- What Constitutes a “Safe Harbor” in an Anti-Kickback Statute Investigation? – Learn about some of the affirmative “safe harbor” defenses that are available in cases involving allegations of offering, soliciting, paying, and receiving illegal remuneration.
- What Kinds of Billing and Coding Errors Constitute Health Care Fraud? – Learn more about the types of billing and coding errors that can lead to civil and criminal charges.
- What Types of Activities Are Covered Under the False Claims Act? – Learn more about common allegations and potential defense strategies in federal health care fraud investigations under the False Claims Act.
Schedule a Confidential Case Assessment at Oberheiden, P.C.
If your Wisconsin health care business or medical practice is under federal investigation, we strongly encourage you to contact us for a confidential case assessment. To speak with a senior attorney on our federal health care fraud defense team as soon as possible, call 888-519-4897 or tell us how to reach you online now.