If you’ve been accused of healthcare fraud by CMS or federal agents, taking immediate and decisive action is crucial, so we recommend contacting an experienced health care fraud attorney to represent you. Here are some basic guidelines to help you navigate this challenging situation.‍

Contact an Experienced Health Care Fraud Attorney: The first and most critical step is to consult with an experienced attorney who specializes in healthcare fraud defense. Hiring the best health care fraud attorney available can make a significant difference in the outcome of your case.

Evaluate Your Options: Federal criminal charges might seem daunting, but it’s important to know that not all healthcare fraud cases go to trial. Many are resolved during the investigative stage. An experienced healthcare fraud attorney will assess your case and determine the best course of action, including a strategy to resolve the matter without charges being filed.

Act Quickly to Mitigate Risks: Speed is essential when dealing with federal investigators or health care fraud auditors. The quicker you act, the better your chances are of avoiding prosecution for health care fraud.

Leverage Legal Expertise to Avoid Prosecution: A skilled healthcare defense attorney has the knowledge and experience to handle healthcare fraud and other investigations effectively. They can often prevent cases from escalating to prosecution by intervening early and negotiating with investigators.

By taking these steps, you maximize your chances of resolving the issue favorably and mitigating federal healthcare fraud penalties.

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Healthcare fraud involves a complex web of factors that vary based on whether a matter is civil or criminal. For federal criminal cases, the fundamental elements are contained in 18 U.S.C. 1347, which can apply to:

• Unauthorized Billing: Unauthorized billing involves charging for services, treatments, or equipment that were not provided, were unnecessary, or were not authorized by the patient. This can include billing for phantom patients, duplicate billing, or unbundling services to increase payments.‍
• Upcoding: Upcoding occurs when healthcare providers use billing codes that reflect more expensive services or procedures than those actually performed. This practice aims to increase reimbursement rates from insurance companies or government healthcare programs.
• ‍Kickbacks and Bribes: Healthcare fraud can include kickbacks and bribes, where providers receive payments or other incentives in exchange for patient referrals, prescribing certain medications, or using specific medical devices.‍
• Unnecessary Services: Performing and billing for unnecessary medical services, procedures, or tests that are not medically justified constitutes healthcare fraud.‍
• Identity Theft: Identity theft in healthcare fraud involves using another person’s personal information, such as their insurance details or Social Security number, to obtain medical services or file false claims.‍
• False Cost Reports: Submitting false cost reports or financial statements to government programs like Medicare and Medicaid to inflate reimbursements is another form of healthcare fraud. This involves manipulating the reported costs of services, equipment, or facilities to receive higher payments.‍
• Prescription Fraud: Prescription fraud includes practices such as forging prescriptions, submitting false prior authorizations, or billing for prescriptions that were never dispensed.‍
• Patient Brokering: Patient brokering involves illegally recruiting patients for specific healthcare providers or facilities in exchange for compensation.‍
• False Enrollment Claims: Submitting false enrollment claims to enroll in health insurance plans or government healthcare programs under false pretenses is a form of healthcare fraud, including with respect to credentialing applications.
  

Understanding these elements is crucial for detecting, preventing, and prosecuting healthcare fraud, ensuring that resources are used appropriately and that patients receive the care they need.

Federal conspiracy in healthcare fraud, outlined under 18 U.S.C. 1349, involves collaboration between multiple individuals to execute a fraudulent scheme against the healthcare system. Essentially, it’s when two or more parties agree to commit activities that perpetuate fraud, such as submitting false claims or kickbacks for referrals.

In practical terms, if a health marketer offers unlawful incentives to a doctor to refer patients to a specific pharmacy, and this pharmacy then bills for those referrals, all parties could be charged with conspiracy. The marketer is implicated for offering bribes, the doctor for accepting them, and the pharmacy for generating profits from these illegal referrals.

For defendants facing such charges, it's vital to have skilled legal representation. Firms like Health Law Alliance specialize in dismantling these complex charges. They leverage their expertise to defend clients effectively, offering a viable path to contesting and mitigating conspiracy allegations

Healthcare fraud allegations can lead to a variety of severe penalties. The type of fraud and the number of violations determine the specific consequences, but the implications can be both business-threatening and life-altering. Here’s what to expect if you come under scrutiny for healthcare fraud:

• ‍Recoupments: If accusations involve overbilling Medicare, Medicaid, Tricare, or the DOL, providers and businesses must repay all overbilled amounts and may undergo pre-payment review in the future.
• ‍Program Exclusion: Both civil and criminal healthcare fraud violations can result in exclusion from participating in Medicare, Medicaid, Tricare, and DOL programs.
• ‍Treble (Triple) Damages: Beyond recoupments, entities typically must pay triple the government's actual losses.
• ‍Licensing and Registration Issues: Offenses can lead to the loss of credentialing status, network termination, and disciplinary actions.
• ‍Fines: Both civil and criminal offenses incur hefty fines, often applied on a per-claim basis.
• ‍Federal Imprisonment: In criminal cases, practitioners and business owners might face years, or even decades, in federal prison.

Understanding these potential penalties highlights the gravity of healthcare fraud allegations and underscores the importance of compliance in healthcare practices.

Healthcare fraud, waste, and abuse ("FWA") encompass a variety of activities that can result in severe legal consequences for providers, although some types of conduct are more likely to result in charges than others. Here are a few categories of conduct that can result in healthcare fraud investigations or charges:

• Prohibited Referrals: Referral arrangements that violate the federal Anti-Kickback Statute (AKS) by offering, paying, soliciting, or accepting remuneration in exchange for patient or prescription referrals
  
• Falsification of Records: Altering or fabricating test results, prior authorizations, or patient records to deceive payers and obtain coverage for an item or service.‍
• Overbilling Government Programs: Charging Medicare, Medicaid, Tricare, the Department of Labor (DOL), or Veterans Affairs (VA) for medically unnecessary services.‍
• Billing and Coding Violations: Engaging in practices like upcoding, unbundling, double-billing, or "phantom" billing to receive higher reimbursements.

This is a non-exclusive list, and any type of conduct that results in the submission of a "false" claim to the government or private payor may form the basis for federal healthcare charges.

Healthcare fraud is investigated by a variety of state and federal agencies. Key federal agencies include the U.S. Department of Health and Human Services, Office of Inspector General (HHS OIG), Centers for Medicare and Medicaid Services (CMS), and the U.S. Department of Justice (DOJ). These agencies work diligently to identify fraudulent activities within the healthcare system.

Investigative agencies that perform the legwork necessary for complex healthcare fraud investigations include the Federal Bureau of Investigation (FBI), OIG, Internal Revenue Service (IRS), and Drug Enforcement Administration (DEA).

Beyond federal entities, Medicaid Fraud Control Units (MFCUs) operate at the state level to scrutinize state-specific Medicaid fraud cases. Contractors working with CMS, such as Medicare administrative contractors (MACs), recovery audit contractors (RACs), and uniform program integrity contractors (UPICs), audit healthcare providers extensively. Among other contractors, you may be familiar with Noridian, Safeguard Services, or Qlarant.

Furthermore, private insurance companies and benefit managers employ their own Special Investigative Units (SIUs) to ensure participating providers comply with regulations and prevent fraudulent activities. Many healthcare fraud cases are started by a SIU referral to the government.