Challenging Healthcare Fraud Charges Due to Billing Errors

Challenging Healthcare Fraud Charges Due to Billing Errors

Healthcare fraud is a growing issue. With healthcare costs on the rise, government agencies like Medicare and Medicaid lose billions of dollars each year to fraudulent billing. But what happens when a healthcare provider gets accused of fraud when they actually just made some innocent billing mistakes?

It can be scary and overwhelming to face fraud charges. Even if you didn’t intentionally try to defraud anyone, sorting out billing errors from fraud can be complicated. This article will break down common billing mistakes that can lead to fraud accusations, your rights in challenging charges, and key defenses you can use.

Why Innocent Billing Errors Get Flagged as Fraud

Government healthcare programs have gotten more aggressive about combatting fraud in recent years. Technologies like data analytics help identify abnormal billing patterns that may indicate fraud. But these methods aren’t perfect.

Many times, innocent mistakes lead to fraud investigations. Common examples include:

• Unintentional coding errors
• Billing for unnecessary services due to lack of understanding, not deliberate fraud
• Using outdated billing codes
• Billing errors due to poor recordkeeping or miscommunication

When auditors detect unusual billing, they often assume it’s fraud. But unusual claims can also come from:

• Rare or complex medical cases
• Innovative new treatments
• Honest mistakes

So before an investigation even begins, auditors can make wrong assumptions. And once an investigation starts, the pressure to prosecute fraud can lead to more unfair conclusions.

What To Do If You Get a Medicare or Medicaid Audit Notice

If Medicare, Medicaid, or another auditor sends you a letter about an upcoming audit or investigation, stay calm. Just because they suspect fraud does not mean you will face criminal charges.

Carefully read any letters to understand what billing or services they are reviewing. Then inspect your own records to try spotting any issues they may have identified. If possible, consult with legal counsel early for advice on responding.

Cooperate fully with the audit and be as transparent as you can. Explain any billing errors you discover, emphasizing they were unintentional mistakes. You may need to repay any identified overpayments, but framing errors as just that rather than fraud can help.

If Fraud Charges Get Filed, Understand Your Rights

Hopefully an innocent billing mistake does not progress to formal criminal charges. But if it does, know that you still have rights in challenging accusations. Some key rights include:

• Presumption of innocence: The burden is on prosecutors to prove intent and knowledge of wrongdoing beyond reasonable doubt.
• Trial by jury: Fraud involving over $100 of false claims carries potential prison time, so you can request a jury trial.
• Defense counsel: If you cannot afford an attorney, the court appoints one.
• Access evidence: Through the discovery process, the prosecution must share their evidence so your lawyer can inspect it.
• Remain silent: You can choose not to testify or answer questions. Your silence cannot imply guilt.

Lean on these rights, and know that the justice system still presumes you innocent unless prosecutors can definitively prove otherwise.

Building Your Defense Against Fraud Charges

With experienced legal help, you can fight fraud accusations and avoid fines or jail time. A strong defense will show prosecutors your intent was not to defraud.

Here are some effective defense strategies to employ:

1. Show the Billing Issues Were Errors, Not Intentional Misrepresentations

Prosecutors must prove you knowingly and willfully committed fraud. If billing problems stemmed from innocent mistakes, sloppy recordkeeping, miscommunication, or lack of understanding, argue those points.

Present evidence like:

• Documentation showing your original patient records and billing records do not match due to errors, not deliberate changes
• Office policies and procedures demonstrating you tried billing properly
• Training materials indicating you trained staff on compliance

Evidence that you did not actually know about billing problems at the time can defeat charges that require proving your intent.

2. Demonstrate Good Faith Efforts to Comply with Billing Rules

Showing that you tried to bill properly can prove you did not intend to defraud. Documents that help include:

• Compliance training records
• Billing education certificates
• Documentation that you consulted Medicare resources for guidance
• Copies of newsletters or emails reminding staff of billing rules

Pointing to compliance efforts indicates you acted in good faith and errors arose despite your attempts to bill appropriately.

3. Highlight the Complexity of Billing Rules

When billing regulations are extremely complex, mistakes can happen easily. In your defense, emphasize how hard billing can be:

• Explain the dense CPT, ICD-10, and HCPCS manuals
• Describe complicated CMS guidance with frequent changes
• Note absurd levels of precision required in coding
• Present professional organization resources you used trying to comply

Clarifying the intricate rules can show the jury how errors could unintentionally occur.

4. Use Experts to Support Your Defense

Neutral expert witnesses can explain to the jury how innocent mistakes versus intentional fraud appear differently. Helpful experts may include:

• Medical coding experts: Can analyze your records and explain how unintentional coding errors led to billing problems
• Compliance officers: Can describe the complexity of billing regulations and how mistakes frequently happen
• Medical ethicists: Can testify to your moral character and ethics as a healthcare professional

Experts carry credibility and insight to demonstrate the nature of errors rather than calculated fraud.

Negotiating Settlements in Fraud Cases

Even with a strong defense, fraud cases sometimes end in a settlement to avoid prolonged court battles. In settlements, prosecutors press for big fines and admissions of guilt. Defense attorneys aim for reasonable fines and no admission of intent to defraud.

In negotiating, consider trying strategies like:

• Offering to implement a rigorous compliance program
• Volunteering for external audits for 1-2 years
• Suggesting a fine proportional to the amount in dispute rather than the maximum
• Proposing community service to demonstrate good faith

Tactics like these can help secure a favorable settlement allowing you to move forward.

Avoiding Future Billing Errors

Getting accused of healthcare fraud often prompts providers to overhaul their billing practices. Steps to help avoid issues down the road include:

• Investing in regular compliance training for all staff
• Implementing tighter oversight procedures for billing operations
• Upgrading to technologies that flag potential errors
• Contracting external audits annually as preventative checks

Addressing compliance proactively reduces chances of another fraud case, provides evidence to defend against charges, and most importantly gives patients ethical, honest care.

Facing Medicare or Medicaid fraud charges can be frightening and overwhelming. But even if billing mistakes led investigators to make allegations, experienced legal defense can help demonstrate your innocence. Know your rights in fighting healthcare fraud accusations while also taking responsibility for any errors. With persistence and an ethical defense strategy, you can defeat fraud charges and move forward.