It seems that the more changes are made to the United States health care, the more complex the regulations become, which makes it more difficult to control their observance and ultimately gives way to more criminal investigations, prosecutions and convictions. We at Norman Spencer Law Group routinely defend patients and physicians, nurses, dentists, therapists, chiropractors, pharmacists, as well as corporate clients – hospitals, pharmacies, private practices, home health agencies, medical equipment providers, medical laboratories, nursing homes, and insurers, in audits, criminal investigations and court proceedings.

Investigations into alleged healthcare fraud are conducted both on federal and state levels. Federal agencies authorized with this task are the following:

• Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) of the Dept. of Health and Human Services;
• Defense Criminal Investigative Service of the Dept. of Defense;
• Dept. of Justice through the FBI and U.S. Attorney General’s Office

Healthcare fraud lawyers at our law firm have dealt with all of these governmental bodies in multiple situations. Any healthcare provider should realize that one day their practice may be audited or investigated. Considering the confusing nature of the existing regulations, you may be in trouble even though you did not intend to violate the rules. This could be extremely disruptive to business operations and staff morale. In order to minimize the exposure and business disruption, you must think ahead and prepare a plan that will address this situation. Speaking with our experienced insurance fraud attorneys before agents appear at your door can resolve many issues before they arise.

If your practice or some of your employees are under audit or investigation, get in touch with us immediately to discuss your matter. There are multiple things that can spark off investigations into alleged fraud by providers and beneficiaries. Follow the link below to learn them.

READ MORE: What Triggers Medicaid Fraud Investigations in New York

If you are accused of such offenses, the consequences may be severe even if no conviction is obtained. Criminal proceedings may tarnish your reputation as a medical professional and consequently make you lose your clients. If the prosecutors manage to secure a criminal conviction, you may be excluded from participating in federal health care programs for a minimum of 5 years or, at worst, permanently.

The conviction will inevitably lead to disciplinary proceedings that may result in medical license loss. The person may also be denied hospital privileges. Besides that, the person will be obliged to pay restitution and may face prison time and steep fines. Health care corporations charged with fraud may be banned from doing business with the government, which will lead to bankruptcy.

As you may see, criminal investigations and charges are not something to be taken lightly, and the way you address the issue at the very beginning will most likely affect the outcome of the situation. Below is a roadmap describing what you should do if you learn that you are a subject of such investigation.

1.The first thing you should know is that by attempting to cope with the situation with your own forces is fruitless. Most likely it is the first time you end up with the issue, so you’d better seek help from someone who has handled it multiple times – a competent healthcare fraud lawyer.

2. Don’t allow any officials to inspect files in your office unless they have a search warrant. Don’t destroy or alter any files and records and don’t instruct your staff to do so or to lie. This will aggravate the situation and complicate your defense.

3.Don’t talk to the investigators and don’t let them interrogate your staff. Tell them politely that first, you need to discuss the situation with a lawyer – and do so immediately. Contact our healthcare fraud defense attorneys for help!

Defending healthcare fraud cases requires quite narrow expertise and thus shouldn’t be handed to general criminal lawyers – only to healthcare fraud attorneys. This is the kind of lawyers our New York firm has on board, and they routinely represent clients in interactions with all investigative agencies conducting healthcare fraud investigations. We also have defended multiple clients in trials and appeals. Check out just a few of our cases.

Billing for Services Not Provided

One prevalent type of healthcare fraud involves billing for services that were never rendered. This occurs when healthcare providers submit claims to insurance companies or government programs like Medicare and Medicaid for treatments or services that were not actually provided to patients. This fraudulent activity leads to significant financial losses for insurance companies and federal programs, ultimately burdening taxpayers and increasing healthcare costs.

Upcoding and Unbundling

Upcoding and unbundling are other common fraudulent practices. Upcoding occurs when healthcare providers use billing codes that reflect more expensive treatments or services than those actually provided. This results in higher reimbursements from insurance companies or government programs. Unbundling involves separating services that are typically billed together to maximize reimbursements. Both practices are illegal and can lead to severe penalties if detected.

Kickbacks and Referrals

Kickbacks and improper referrals are also significant issues in healthcare fraud. These occur when healthcare providers receive payments or other incentives in exchange for referring patients to specific services, suppliers, or facilities. This practice violates the Anti-Kickback Statute and can compromise patient care by prioritizing financial gain over medical necessity.

Medicare and Medicaid Fraud

Medicare and Medicaid fraud encompasses a wide range of fraudulent activities, including false claims, identity theft, and fraudulent billing practices. Given the substantial funds allocated to these programs, they are frequent targets for fraudsters. Combating Medicare and Medicaid fraud is a priority for law enforcement agencies, as it directly impacts the availability and quality of healthcare for millions of Americans.

Investigating the Charges

When facing healthcare fraud charges, a thorough investigation is crucial. Norman Spencer Law Group takes an in-depth approach to examining the allegations against their clients. This involves reviewing all relevant documents, billing records, and communications to identify discrepancies and potential defenses. The firm’s attorneys work diligently to uncover any weaknesses in the prosecution’s case, ensuring that no stone is left unturned.

Developing a Defense Strategy

Crafting a robust defense strategy is essential for any healthcare fraud case. The attorneys at Norman Spencer Law Group develop personalized strategies based on the unique aspects of each case. This might include demonstrating that billing errors were unintentional, that the services billed for were indeed provided, or that the client was unaware of any fraudulent activity. The goal is to create a compelling narrative that casts doubt on the prosecution’s claims and highlights the client’s innocence.

Negotiating with Prosecutors

Negotiation plays a key role in many healthcare fraud cases. Norman Spencer Law Group’s attorneys are skilled negotiators who work tirelessly to achieve favorable outcomes for their clients. This might involve negotiating plea agreements, reducing charges, or seeking alternative sentencing options. By engaging with prosecutors early and effectively, the firm aims to mitigate the potential consequences for their clients.

Representing Clients in Court

If a case goes to trial, having experienced legal representation is imperative. Norman Spencer Law Group’s attorneys are seasoned litigators who have successfully defended clients in court. They present a strong defense, cross-examine witnesses, and challenge the prosecution’s evidence to protect their clients’ rights. Their courtroom experience and dedication to their clients ensure a vigorous defense throughout the trial process.