Medicare Fraud Defense

There are numerous ways that you could commit Medicare fraud, some that aren’t intentional. If you’ve received allegations about this type of activity that could have taken place in your medical office, it’s important to seek the assistance of an attorney who can look at the evidence in place before putting together a defense. If there is not enough evidence to substantiate the claims against you, then a possible defense could be that you were unaware that any kind of Medicare fraud was taking place in the office or that it wasn’t taking place in an intentional fashion. However, if you know that you have committed this kind of fraud, then you need to work with your attorney to present why it occurred and how you can make changes so that it doesn’t happen again. You also need to work with your attorney to put together a proper defense to try to keep your medical license so that you can continue practicing in the medical field.

Understanding Medicare Fraud

Before meeting with an attorney, you need to understand what could be considered as Medicare fraud. One of the easiest ways to commit Medicare fraud is by billing for medical services that aren’t needed or that aren’t performed. Home healthcare services are also included in this type of fraud as you could file for services that are provided when they aren’t Pharmacy fraud could also occur as Medicare payments could be accepted for prescriptions that aren’t filled or that are filled for a generic brand while Medicare is charged for the name brand. Upcoding is a common way to commit this type of fraud as well. This often means that more codes are billed for instead of only the codes associated with a diagnosis or service provided.

Working with Your Attorney

When working with your attorney, you’ll often have to provide copies of financial records that relate to Medicare payments. There’s usually a time frame that has been investigated, which usually means that you’re only going to need to submit documents for that time frame to your attorney. Try to submit witness statements and other details from healthcare professionals in the office who know that Medicare fraud has not taken place. If there are workers in the office or hospital who have committed this type of fraud without your knowledge, then you need to take the proper actions against those workers while also submitting the proper documents associated with the workers involved. These documents could be used in the defense that your attorney puts together to try to get your sentence minimized or to get the charges against you dropped.

DEFENSE TEAM SPOTLIGHT

Todd Spodek

Lead Attorney & Founder

Featured on Netflix's "Inventing Anna," Todd Spodek brings decades of high-stakes criminal defense experience. His aggressive approach has secured dismissals and acquittals in cases others deemed unwinnable.

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Legal Scenario: What Would You Do?

Scenario

You are a physician who recently received a letter from the Office of Inspector General stating that your practice billed Medicare for office visits at higher complexity levels than what patient records support. Federal investigators are now requesting access to your billing records from the past three years.

Could I really face criminal charges just for the way my office coded patient visits?

Attorney's Answer

Yes, upcoding is one of the most commonly prosecuted forms of Medicare fraud under 18 U.S.C. § 1347, which carries penalties of up to 10 years in prison per count. The government often uses statistical sampling of your claims to extrapolate alleged overpayments, so even a handful of miscoded visits can balloon into millions in alleged losses. However, a strong defense can challenge the government's coding interpretations by retaining independent medical coding experts who review your documentation and demonstrate that the services billed were medically necessary and properly supported. Early intervention by your attorney to respond strategically to the OIG inquiry can sometimes prevent criminal referral to the Department of Justice entirely.

This is general information only. Contact us for advice specific to your situation.

The attorney you hire needs to be one who understands healthcare and who is able to write the proper letters and statements on your behalf whether the details involve defending your actions or submitting details that indicate you didn’t commit fraud. It’s important to begin putting together a defense as soon as you receive details from the state or a federal agency in order to possibly keep your license throughout the process.