Wisconsin Healthcare Fraud Defense
If your Wisconsin healthcare 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 healthcare fraud defense team in confidence, call
Federal authorities are targeting healthcare 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, healthcare 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 healthcare 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 Healthcare Fraud Defense Attorneys Serving Wisconsin Providers
At Oberheiden, P.C., our federal healthcare fraud defense team provides legal representation for physicians, pharmacists, and other healthcare 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 healthcare fraud. Examples of our success include:
- Avoiding referrals to the U.S. Attorney’s Office as a result of healthcare audits.
- Protecting the substantial majority of our clients against criminal charges.
- Dismissing criminal indictments for federal healthcare fraud.
- Resolving numerous investigations with the result of no civil or criminal liability for our client.
Meet the federal healthcare fraud defense team at Oberheiden, P.C.
Experience Representing Healthcare Providers in Wisconsin and Nationwide
Our healthcare fraud defense practice consists of representing patient-facing providers, suppliers, and other entities that bill federal healthcare 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 healthcare 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 Healthcare 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 healthcare 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 healthcare 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. Healthcare 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 Healthcare Fraud Investigations in Wisconsin
Q: What is the Eliminating Kickbacks in Recovery Act?
In an effort to reduce the profitability of referring patients in need of drug and alcohol treatment, the U.S. Congress passed the Eliminating Kickbacks in Recovery Act (EKRA) in 2018. The EKRA forbids accepting or paying kickbacks for referrals to recovery homes, clinical treatment facilities, or laboratories. The EKRA is not only focused on the facilities receiving payments, such as recovery homes, clinical treatment facilities, and laboratories, but also on the physicians who make referrals to these organizations. If you operate a recovery home, clinical treatment facility, or laboratory or refer patients to these practices, it is critical that you speak with an experienced Wisconsin federal healthcare fraud defense attorney about the referral arrangement.
Q: How do I know if my investigation is civil or criminal in nature?
Determining whether a federal healthcare 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 am aware of billing errors or deficiencies in my practice’s compliance program?
This can be a delicate situation, as healthcare 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.
Q: Why does the DEA target Wisconsin doctors?
Wisconsin physicians are targeted by the DEA in investigations focusing on prescription abuse, medically unnecessary opioids, drug diversion, and responsibility for accidental patient overdoses. The investigations are organized by the Department of Justice in Washington D.C. and are incredibly serious. Physicians of all specialties that have prescribed controlled substances to chronic pain patients or dispensed opioids outside the ordinary course of their practice (“pill mill”) should consult with DEA defense attorney Dr. Nick Oberheiden immediately to avoid becoming the next victim of search warrants and federal arrest of hard working physicians.
Q: What penalties could Wisconsin physicians face in opioid investigations?
21 U.S.C. 841 under the Controlled Substances Act governs penalties for pain prescription violations. Pursuant to this drug diversion and drug distribution statute, physicians, who are found guilty of having illegally dispensed controlled substances, face hefty criminal fines, a revocation of their DEA and medical license, and up to 10 years federal incarceration per occurrence.
Additional Resources for Wisconsin Healthcare Providers
When facing a federal healthcare fraud investigation, the more you know, the better. Here are five additional resources for healthcare providers prepared by the experienced federal defense attorneys at Oberheiden, P.C.:
- Glossary: Understanding Your Federal Healthcare Fraud Investigation – Learn about some of the key legal terms involved in healthcare fraud investigations.
- Q&A with Federal Healthcare 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 Healthcare 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 healthcare fraud investigations under the False Claims Act.
Schedule a Confidential Case Assessment at Oberheiden, P.C.
If your Wisconsin healthcare business or medical practice is under federal investigation, we strongly encourage you to contact us for a confidential case assessment. Contact our federal defense team and speak to a senior healthcare fraud attorney as soon as possible, call 888-680-1745 or tell us how to reach you online now.