The healthcare industry is probably the most heavily regulated industry in the U.S. As a healthcare provider, you don’t want to find yourself facing allegations of healthcare fraud, whether it involves medicaid fraud, medicare fraud, or billing violations. They can quickly escalate into a series of federal investigations.
For practice owners, physicians, billing managers, healthcare companies, and billing executives, even a slight suspicion of medicare fraud can put livelihoods, licenses, and careers at risk. In this guide, we’ve outlined what healthcare providers need to know when facing a healthcare fraud investigation.
What Qualifies as Healthcare Fraud Under Federal Law?
Fraud in the healthcare industry typically involves allegations that you, as a healthcare provider, have knowingly submitted misleading or false claims to healthcare programs like Medicaid and Medicare.
Federal prosecutors may pursue cases under laws such as the False Claims Act, conspiracy laws, and healthcare fraud statutes. Common allegations include overbilling, false claims, upcoding, billing for services that were never provided, and charging for medically unnecessary procedures.
It is important to note that a healthcare fraud case is not always a result of intentional wrongdoing. Most federal healthcare fraud investigations normally arise from coding disputes, outsourcing billing to third parties, or different interpretations of complicated reimbursement requirements.
If you are facing a healthcare fraud investigation, it’s crucial that you contact an experienced healthcare fraud attorney like Nick Oberheiden. Early intervention is critical in these cases. You also want to understand the federal government’s theory of your case.
What Triggers Healthcare Fraud Investigation?
Most of these fraud investigations usually start quietly, and you won’t even know you are being investigated until federal agents issue subpoenas, summon you for interviews, or come to your facility with search warrants.
Investigations may be triggered by data analytics, audits, former employees, whistleblower complaints, or referral programs from agencies like the Office of the Inspector General.
Federal agents may have been investigating you for months or even years before making contact. That is why seeking legal guidance early can be crucial when facing suspected healthcare fraud investigations.
Common Healthcare Fraud Allegations Healthcare Providers Should Know About
Federal prosecutors often examine billing and referral practices, including:
- Upcoding, where higher-paying billing codes are allegedly used instead of the appropriate codes
- Overbilling for the time, frequency, or complexity of services provided
- False billing for services that were never performed
- Billing for services that are allegedly medically unnecessary
- Improper financial arrangements or kickbacks tied to patient referrals
These allegations can result in civil penalties, criminal charges, exclusion from federal healthcare programs, and potential professional licensing consequences.
What to Do If You’re Under Federal Investigation or Being Charged
One of the biggest mistakes you can make is trying to explain billing practices to investigators without legal counsel. Early statements can be misunderstood or later used to support allegations of intent. If federal agents contact you, receive a subpoena, or learn of an audit related to potential fraud, seeking experienced federal defense counsel promptly is essential.
Early legal intervention can influence the direction of a healthcare fraud investigation, help protect constitutional rights, and, in some cases, reduce the risk of criminal charges being filed.
Endnote
Healthcare fraud cases are often pursued aggressively because they involve federal funds and government healthcare programs. The consequences are also dire and may include substantial fines, prison sentences, restitution demands, asset forfeiture, and exclusion from government programs like Medicaid and Medicare.
Healthcare fraud allegations can progress quickly as well. Whether you are under investigation, have received a subpoena, or are already facing charges, the decisions made early in the process can have a significant impact on the outcome. Most importantly, you need an experienced healthcare fraud lawyer on your side to protect your rights, future, and reputation.
